CNJ 28_1_2_prelims.qxd
14/07/2008
A
12:04 PM
Page i
dvances in Contemporary Transcultural Nursing SECOND EDITION
CONTEMPORARY NURSE
·
APRIL 2008
·
VOLUME 28
·
ISSUE 1–2
Transcultural nursing: Pathways of cultural awareness
Edited by
AKRAM OMERI Adjunct Associate Professor, University of Western Sydney NSW, Australia
and MARILYN McFARLAND Associate Professor, University of Michigan, Flint MI, USA ISBN 978-0-9757710-5-1
e C ontent
PTY
management LTD
Sydney • Amsterdam • Palo Alto
CNJ 28_1_2_prelims.qxd
14/07/2008
12:04 PM
Page ii
Published in Australia by: eContent Management Pty Ltd PO Box 1027, Maleny QLD 4552, Australia Tel. +61-(0)7-5435 2900 Fax: +61-(0)7-5435 2911 E-mail:
[email protected] ABN 87 091 432 567 SAN 902-4964 Affiliates in: Sydney, Amsterdam, Palo Alto A special issue of the Contemporary Nurse journal: Volume 28 Issue 1–2 (April 2008) Advances in Contemporary Nursing – ISSN 1832-9861 – 4 volumes per annum from 2006 2008: Volume 9: Advances in Contemporary Aged Care – ISBN 978-0-9757710-1-3 Volume 10: Advances in Contemporary Palliative and Supportive Care – ISBN 978-0-9757710-4-4 Volume 11: Advances in Contemporary Transcultural Nursing, 2nd edn – ISBN 978-0-9757710-5-1 Volume 12: Advances in Contemporary Nursing History & Midwifery in Australia – ISBN 978-0-9775742-8-5 2007: Volume 5: Advances in Contemporary Indigenous Health Care – ISBN 978-0-9750436-9-1 Volume 6: Advances in Contemporary Community and Family Health Care – ISBN 978-0-9757710-2-0 Volume 7: Advances in Contemporary Nurse Recruitment and Retention – ISBN 978-0-9757710-0-6 Volume 8: Advances in Contemporary General Practice Nursing – ISBN 978-0-9757710-3-7 2006: Volume 1: Advances in Contemporary Transcultural Nursing – ISBN 978-0-9750436-1-5 Volume 2: Advances in Contemporary Child and Family Health Care – ISBN 978-0-9750436-3-9 Volume 3: Advances in Contemporary Mental Health Nursing – ISBN 978-0-9759436-8-4 Volume 4: Advances in Contemporary Nursing and Interpersonal Violence – ISBN 978-0-9750436-6-0 Contact the publisher for annual subscription details (Boxed Sets):
[email protected] Advances in Contemporary Transcultural Nursing, Second Edition Bibliography ISBN 978-0-9757710-5-1 1. Transcultural nursing 2. Transcultural nursing – case studies 3. Culture care theory 4. Ethnonursing 5. Cultural competency 6. Nurse leadership 7. Faith-based health 8. Muslim health 9. Indigenous health 10. Collaboration I. Omeri, Akram II. McFarland, Marilyn (Series: Advances in Contemporary Nursing – ISSN 1832-9861) © 2008, eContent Management Pty Ltd This publication is copyright. Other than for purposes of and subject to the conditions prescribed under the Copyright Act, no part of it may in any form or by any means (electronic, mechanical, microcopying, photocopying, recording or otherwise) be reproduced, stored in a retrieval system or transmitted without prior written permission. Inquires should be addressed to the Publisher at:
[email protected] Publisher: James H. Davidson, eContent Management Pty Ltd Peer Review Coordinator: Jenny Gibson, eContent Management Pty Ltd Printed in Malaysia by Vivar Printing Sdn Bhd, Selangor D.E.
CNJ 28_1_2_internal.qxd
14/07/2008
CN
12:22 PM
Page iii
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: iii–v.
FOREWORD
MADELEINE M LEININGER PhD, LHD, DS, RN, CTN, FRCNA, FAAN
Professor Emeritus of Nursing College of Nursing Wayne State University Detroit MI, USA and The University of Nebraska Medical Centre College of Nursing Omaha NE, USA and Founder Transcultural Nursing and Human Care Research
T
ranscultural nursing continues to expand worldwide to provide culturally congruent care to cultures that in the past have often been overlooked, avoided, feared, neglected, or misunderstood. From the beginning of transcultural nursing, the goal of this new discipline has been to provide humanistic, safe, and meaningful care to people of diverse cultures in the world. Slowly, this goal is being promoted and maintained by nurses and other health providers who have been prepared in the field. These transcultural nurses contend that all cultures have a right to have their values, beliefs, and lifeways recognised, respected, and upheld for their health and well-being. It is most encouraging to have this Second Issue come forward to move further to examine contemporary trends and advances in transcultural nursing. Dr Akram Omeri and Dr Marilyn McFarland are to be commended for their leadership. For several decades, Dr Omeri has been an outstanding leader in multicultural Australia to prepare nurses to provide transcultural nursing care. She has been a very active leader to initiate undergraduate and graduate seminars for
nurses and nursing students with field experiences in transcultural nursing. Dr Omeri has conducted several noteworthy and breakthrough research studies on local and indigenous cultures in Australia.These enthonursing research studies were the first of their kind in the country. As a consequence, Dr Omeri has served as an outstanding role model for research and education in transcultural nursing and to stimulate nurses to discover new ways to serve diverse cultures. Dr Omeri was the first Australian nurse to obtain graduate preparation in transcultural nursing. She became the first certified transcultural nurse in Australia and provided a pathway to help local (including Indigenous) nurses to become transcultural nurses. Dr Omeri was the first to create the TCN-Cooperative Society (RCNA) which has been a very influential force nationally and internationally for transcultural nursing. She has been active in local, national and international transcultural programs through the Royal College of Australia’s dynamic programs. She has been an outstanding role model, advocate and pioneer leader to open the doors to study and practice transcultural nursing. She
Volume 28, Issue 1–2, April 2008
CN
iii
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:22 PM
Page iv
Madeleine M Leininger
was also the first to be awarded the Distinguished TCN Scholar Award by the Transcultural Nursing Society, and the prestigious Leininger Award in 1998. Dr Omeri has been active in many other ways to promote, maintain, and establish transcultural nursing standards of practice in teaching, research, and education. Her leadership in Australia has been outstanding and appreciated. This special issue of the Contemporary Nurse journal, Advances in Contemporary Transcultural Nursing, 2nd edition, is truly another creative venture from Professor Omeri. Marilyn McFarland received her doctorate in nursing with a focus on transcultural nursing under the mentorship of Dr Madeleine Leininger at Wayne State University, Detroit MI (USA) in 1995, and is currently an associate professor of nursing at the University of Michigan-Flint, USA where she teaches at the undergraduate and graduate levels. Dr McFarland has directed her professional work toward the care and study of elders from diverse cultures throughout the United States. She is a former editor of the Journal of Transcultural Nursing and is active worldwide in the Transcultural Nursing Society. Dr McFarland also teaches transcultural nursing courses and presents her research findings about the culture care of elders locally, nationally and worldwide. As a Certified Transcultural Nurse and as an American Nurse Credentialing Center (ANCC) certified family nurse practitioner, Dr McFarland integrates transcultural knowledge and care into her primary care clinical practice. This second edition of Advances in Contemporary Transcultural Nursing builds upon the first edition (Volume 15 Issue 3, October 2003). However, the second goes further and focuses on contemporary transcultural nursing practices, research and education to provide culturally congruent care.This is the central purpose and goal of transcultural nursing. Of special interest, this volume will focus on human rights of immigrants and refugees as they transition from one geopolitical and ecological area to many different iv
CN
Volume 28, Issue 1–2, April 2008
places in the world.This transition is often very difficult as cultures move from very different environments in which political, economic, and cultural factors are extremely ambiguous and uncertain for immigrants. Transcultural nurses prepared through graduate education programs with guided mentoring experiences by qualified nurse instructors are skilled in ways to respond appropriately to immigrant care needs as they attempt to maintain their cultural beliefs and practices as they adapt to new lifeways. Dr Omeri and Dr McFarland, as transcultural specialists, are keenly aware that historical and political factors play a major role in health and illness conditions for refugees and immigrants. These transcultural nursing specialists can identify diverse cultural forces that influence illness and well-being.They can help immigrants adjust to complex and difficult situations in meaningful ways. It is, therefore, encouraging that this issue will explicitly address these factors, especially human rights and cultural beliefs and values of immigrants and refugees. In keeping with the philosophy and goals of transcultural nursing, specific cultural values, needs and practices of different cultures will be emphasized. In-depth studies of cultures will be essential to advance nursing care knowledge to provide culturally congruent care and to identify new practices that are beneficial to cultures. Accordingly, diverse theoretical approaches and both qualitative and quantitative research methods will be encouraged. In addition, the search for care universals or commonalities and diversities among and between cultures will continue to be explored in keeping with the nature and unique focus of transcultural nursing. This second edition is most timely to advance transcultural nursing knowledge and to encourage interdisciplinary dialogue. Currently, many disciplines are just beginning to discover the importance of culturally congruent care and transcultural education and practice, so they will find this publication a welcome addition to their
CNJ 28_1_2_internal.qxd
14/07/2008
12:22 PM
Page v
Foreword endeavors. As all health disciplines realise that globalisation is a major focus in our world, transcultural education and practice will be recognised as essential in our world today and in the future. Fortunately, the knowledge and practices of transcultural nursing established since the early 1950s will become more fully recognised and appreciated as globalisation increases and healthcare becomes transformed from largely a unicultural to a multicultural focus. This issue will show ways that transcultural nursing will be
CN
valued as a discipline to meet the essential needs of diverse cultures. Undoubtedly, many new insights and practices will be forthcoming from this edition as well as reaffirming knowledge and practices already established in transcultural nursing. Dr Omeri and Dr McFarland are to be applauded for the issue and its special transcultural foci. I welcome the contribution of authors to this transcultural nursing publication in order to advance the status of the discipline.
ORDER FORM ADVANCES IN CONTEMPORARY TRANSCULTURAL NURSING 2ND EDN Edited by Akram Omeri and Marilyn McFarland ISBN: 978-0-9757710-5-1; xii + 212 pages; softcover A special issue of Contemporary Nurse (Volume 28, Issue 1–2, April 2008) Prices include airmail freight on all orders and GST (for Australian customers) North America, Europe, North East Asia & Middle East: Institutions US$148.50; Individuals US$77.00 ANZ, Pacific, South & South East Asia, South America & Africa: Institutions AU$148.50; Individuals AU$77.00 incl postage. Students receive a 20% discount on the respective individual price Number of copies:
Total: US$
Total: AU$
A cheque made payable to eContent Management Pty Ltd is enclosed OR Please charge this purchase to my Mastercard/Visa/Bankcard My full card number is:
/
Cardholder Name:
/
/
Expiry date:
/
Signature:
Please send this order to the address below by airmail: Name of Institution:
Name of Individual:
Street address (or PO Box): City: Tel. (with area code): Email:
State:
Zipcode:
Country:
Fax: (with area code): Your reference:
Fax the completed order form to +61-7-5435-2911 or post with cheque to: eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Email:
[email protected] www.contemporarynurse.com
Volume 28, Issue 1–2, April 2008
CN
v
CNJ 28_1_2_internal.qxd
A
31/07/2008
12:46 PM
Page vi
dvances in Contemporary Transcultural Nursing SECOND EDITION VOLUME 28
F I N A L
I S S U E
O F
T H I S
V O L U M E
CONTENTS iii ix
ISSUE 1–2
·
APRIL 2008
FOREWORD — Madeleine M Leininger PREFACE: Pathways of cultural awareness — Akram Omeri SECTION 1: TRANSCULTURAL NURSING LEADERSHIP AND EDUCATION EDITORIAL: The state of transcultural nursing global leadership and education — Linda J Luna and June Miller
1
Leadership in transcultural nursing The role of RCNA in promoting transcultural nursing as a discipline of study, research, practice and management in Australia — Rosemary B Bryant, Elizabeth R Foley and Elizabeth C Percival
3 13
COMMENTARY: Global leadership in transcultural practice, education and research — Margaret M Andrews Transcultural nursing education EXEMPLAR: Developing a new Bachelor of Nursing course responsive to Australia’s culturally diverse community — Lynette M Raymond
17 23
Use of the culture care theory and ethnonursing method to discover how nursing faculty teach culture care — Sandra J Mixer
37
Cultural competency of graduating US Bachelor of Science nursing students — Suzan Kardong-Edgren and Josepha Campinha-Bacote
CN vi
·
CN
Contemporary Nurse is aggregated/indexed/listed in: Thomson ISI’s Science Citation Index (SCIE) & Social Science Index (SSCI), NLM’s Medline, EmCare, Scopus, Published by PsycINFO, CINAHL, Meditext, Cengage, ProQuest, eContent Management Pty Ltd EBSCO Publishing, Atypon, eBrary, MyiLibrary, PO Box 1027, Maleny NetiLibrary, Questia, eBooks Corp., EBSCOHost, QLD 4552, Australia International Nursing Index, CSA Illumina, Cabell’s, (SAN 902-4964) Ulrich’s Periodicals and DEST Register of Refereed Journals
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
30/07/2008
A
9:45 PM
Page vii
dvances in Contemporary Transcultural Nursing SECOND EDITION
CONTENTS
VOLUME 28
·
ISSUE 1–2
·
APRIL 2008
45 48 64 74 83
F I N A L
I S S U E
O F
T H I S
V O L U M E
SECTION 2: APPLICATION OF TRANSCULTURAL NURSING THEORY AND MODELS TO PRACTICE
98 101 111 119 129 141
EDITORIAL: Transcultural nursing theory and models: The challenges of application — Irena Papadopoulos and Akram Omeri Culture care theory: A proposed practice theory guide for nurse practitioners in primary care settings — Marilyn M McFarland and Marilyn K Eipperle A partnership of a Catholic faith-based health system, nursing and traditional American Indian medicine practitioners — Ann O Hubbert Lebanese cancer patients: Communication and truth-telling preferences — Myrna Abi Abdallah Doumit and Huda Huijer Abu-Saad Bridging generic and professional care practices for Muslim patients through use of Leininger’s culture care modes — Hiba Wehbe-Alamah SECTION 3: TRANSCULTURAL NURSING RESEARCH: WHERE IS THE EVIDENCE? EDITORIAL: Towards a culturally competent nurse workforce — Rhonda Griffiths AM and John Daly Expectations and experiences of recently recruited overseas qualified nurses in Australia — Scott Brunero, Julie Smith and Emma Bates A reflection on culture over time by Baccalaureate nursing students — Hendrika J Maltby Integrative simulation: A novel approach to educating culturally competent nurses — Carolyn M Rutledge, Phyllis Barham, LynnWiles, Richardean S Benjamin, Phyllis Eaton and Kay Palmer Cultural competence in action for CAMHS: Development of a cultural competence assessment tool and training programme — Irena Papadopoulos, Mary Tilki and Savita Ayling Cultural desire: ‘Caught’ or ‘taught’? — Josepha Campinha-Bacote Continues ...
Volume 28, Issue 1–2, April 2008
CN
vii
CNJ 28_1_2_internal.qxd
A
14/07/2008
12:22 PM
Page viii
dvances in Contemporary Transcultural Nursing SECOND EDITION VOLUME 28
CONTENTS
F I N A L
I S S U E
O F
T H I S
V O L U M E
149
162 165 173 189 198 207
211 212
·
ISSUE 1–2
·
APRIL 2008
Perception of nursing care: Views of Saudi Arabian female nurses — Jette Mebrouk SECTION 4: GLOBAL AGENDA IN TRANSCULTURAL NURSING EDITORIAL: Transcultural nursing: The global agenda — Marilyn (Marty) Douglas and Juliene G Lipson Culture-specific care for Indigenous people: A primary health care perspective — Anne McMurray and Rani Param The significance of a culturally appropriate health service for Indigenous Ma-ori women — Denise Wilson Nursing care of vulnerable populations using a framework of cultural competence, social justice and human rights — Dula F Pacquiao Nurses on the move: Diversity and the work environment — Mireille Kingma EPILOGUE: Advancing transcultural nursing through collaboration — Akram Omeri BOOK REVIEWS Culture Care Diversity and Universality:A Worldwide Nursing Theory, 2nd edition, by Leininger MM and McFarland MR (Eds) — Rick Zoucha Transcultural Concepts in Nursing Care, 5th edition, by Andrews M and Boyle J — Sandra J Mixer F I N A L I S S U E O F T H I S VO L U M E
C O U R S E
R E A D E R
This Contemporary Nurse special issue is available for sale independently under its ISBN (978-0-9757710-5-1), or as part of the Advances in Contemporary Nursing series, ISSN 1832-9861, Volume 11
viii
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
CN
12:22 PM
Page ix
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: ix–xi.
PREFACE Pathways of cultural awareness
DR AKRAM OMERI PhD, RN, CTN, FRCNA
Guest Editor Advances in Contemporary Transcultural Nursing Adjunct Associate Professor University of Western Sydney School of Nursing Sydney NSW, Australia
T
ranscultural nursing anticipates similarities and differences in health care and health care systems and nursing practices within diverse cultural contexts and societies. Global development of the discipline of transcultural nursing is dependent upon international collaborative research efforts and the dissemination of knowledge worldwide. This Contemporary Nurse special issue on transcultural nursing, Advances in Contemporary Transcultural Nursing, 2nd edition, is a major collaborative endeavour that aims to share evidence-based transcultural nursing knowledge toward advancing and improving care in culturally meaningful ways to clients, families and communities. It is intended to make a major contribution to the dissemination of transcultural nursing knowledge locally and internationally. The diverse content is structured around four major themes encompassing: leadership and education; the application of models and theories to practice; research evidence for practice and transcultural nursing research incorporating principles of social justice, human rights,
compassion, and human dignity. The four sections of this special issue provide a broad view of the discipline of transcultural nursing, the scope of its interests and the application of research based transcultural nursing knowledge in education, research and practice.
Section 1: Transcultural nursing leadership and education On transcultural nursing leadership, Rosemary Bryant, Elizabeth Foley and Elizabeth Percival present a historical perspective of how transcultural nursing emerged as a discipline of study, practice and research and the national leadership of a national organisation in promoting transcultural nursing in Australia. Margaret Andrews, highlights the global leadership of transcultural nursing(TCN) by the founder of the discipline, Madeleine Leininger, and discusses the leadership of Australian nurses in global transcultural nursing. These two papers highlight the significance of both national and global leadership in TCN. On transcultural nursing education, Lynnette Raymond highlights issues surrounding the development of a Bachelor of Nursing course responsive to cultural diversity. She discusses factors that influenced the development of learning outcomes that would enable student nurses the opportunity to develop the knowledge, skills, and attitudes needed to advance personal and professional cultural awareness of self and others appropriate to the Australian context and delivery of culturally congruent Volume 28, Issue 1–2, April 2008
CN
ix
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:22 PM
Page x
Akram Omeri
and safe nursing care for practice. Sandra Mixer, reflects upon a detailed literature review demonstrating how faculties use culture-care theory and the ethnonursing method to teach culture care.The literature revealed that despite 50 years of transcultural nursing knowledge development through theory, research, and practice; there remains a lack of formal, integrated cultural education in nursing. Cultural competencies of graduating US BSN students is revealed in a joint research article by Suzan Karding-Edgren and Josepha Campinha-Bacote.
Section 2: Application of transcultural nursing theory and models to practice McFarland and Eipperle propose Leininger’s Theory of Culture Care Diversity and Universality as a basis for the educational preparation, primary care contextual practice, and outcomefocused research endeavors of advanced practice nursing. Ann Hubbert presents a historical partnership between an American Catholic faithbased, urban hospital and a program sponsored by a Comanche medicine man on the spirituality of American Indian Traditional Indian. Culture care theory is applied in discussion of these past experiences to explore the relationships among and between the participating cultures. Myrna Doumit and Huda Abu-Saad Huijer report on a study of the lived experiences of Lebanese cancer patients. Using the Utrecht School of Phenomenology, semi-structured interviews with ten cancer patients and subsequent analysis and synthesis of raw data revealed that cancer patients expressed the need for a clear and truthful communication with health care professionals and family members. Hiba Wehbe-Alamah shares knowledge of traditional Muslim generic (folk) care beliefs, expressions, and practices derived from research and descriptive sources in order to assist nurses and other health care professionals to integrate generic care practices into professional care practices. x
CN
Volume 28, Issue 1–2, April 2008
Section 3: Transcultural nursing research: Where is the evidence? A number of studies in this section are used as evidence-base for practice. Brunero, Smith and Bates examined the experiences and needs of a group of Overseas Qualified Nurses’(OQN’s) at a major metropolitan tertiary referral hospital in Australia.The study reports an organisational and personal approach undertaken to assist in the process of adjustment of the participating ONQ’s into the nursing workforce in the context of the tertiary institution where the study took place. In a retrospective descriptive study, Henrietta Maltby reports on reflective responses by 85 junior nursing students to 126 questions on culture over time. Analysis of verbatim descriptors by participants revealed that cultural competency although not yet fully operationalised in the nursing profession is a developmental process that goes across time and is more than learning about cultures. Rutledge et al examine a new approach in educating culturally competent nurses. ‘Integrative simulation’ is used to provide culturally diverse learning opportunities for both university and distance mode students. Cases are developed using focus groups and individual interviews. Papadopoulos, Tilki and Ayling detail the development of a tool to measure cultural competence of individuals working within the Children and Adolescent Mental Health Services (CAMHS). Jospha Campinha-Bacote explores the construct of cultural desire in an attempt to identify meaningful ways that cultural desire cannot only be ‘caught’ by faculty who model this construct, but also be ‘taught’ within nursing curricula as a functional component of cultural competence. Cultural desire is one construct of Campinha-Bacote’s model of cultural competence. Jette Mebrouk reports the findings from a phenomenological research study on perceptions of nursing care by Saudi Arabian female nurses practicing in the context of Saudi Arabia.
CNJ 28_1_2_internal.qxd
14/07/2008
12:22 PM
Page xi
Preface: Pathways of cultural awareness Using in-depth semi-structured interviews with five nurses participating in the study revealed that perception of care is closely linked to Islamic values.
Section 4: Global agenda in transcultural nursing Papers included in this section illustrate the nature and scope of transcultural nursing as a global endeavour. By incorporating the principles of social justice, human rights, compassion, and human dignity, transcultural nurses aim to provide culturally competent care to fellow world citizens, irrespective of their cultural origins, human condition or social situation. Ann McMurray and Rani Param describe how structural, historical and political factors have contributed to the negative health status and health outcomes of Australia’s Indigenous peoples. The authors recommend strategies for overcoming barriers and biases relating to indigenous health. Denise Wilson describes research exploring the health perceptions of Maori women and their interaction with ‘mainstream’ health care services. Findings of the research provide guidance for her recommendations for culturally competent practice for these Maori women. Dula Pacquiao presents a picture of vulnerable populations using a framework of cultural competence, social justice and human rights. She states that transcultural nursing mandates that the principles of social justice, human rights and cultural competence extend as much to
CN
our professional colleagues as they do to our patients and clients. Mireille Kingma raises consciousness of the scope and magnitude of the international nurse recruitment efforts and identifies the types of abuse, discrimination and exploitation reported by migrant nurses and advocates for the development of strategies to prevent and deal with such matters in the name of saving nursing and the profession. Being mindful of the diverse views and approaches in papers submitted, and based upon reviewed evidence-based literature above, we adopted an open mind, taking into account two major constructs essential in transcultural nursing namely ‘Culture and Care’ and how submitted papers could appropriately inform practice toward culturally competent nursing care. This special issue, on Advances in Contemporary Transcultural Nursing builds upon the enormous wealth of evidence-based transcultural nursing knowledge from many parts of the world.
Acknowledgments We are grateful to all those who made submissions to this issue. We also acknowledge the contributions of all who in one way or another have participated in promoting the discipline of transcultural nursing in Australia and globally. We extend our special acknowledgement to Sandy Lovering for her contributions during initial planning of this special issue and to Helen Hamilton, Consulting Editor, for her kind and generous editing upon request.
POST PRESSED Academic Titles from eCONTENT Indigenous Education and the Adventure of Insight: Learning and teaching in indigenous classrooms by Neil Harrison ISBN 1-876682-59-0; $55.00 + p&h Rethinking Indigenous Education: Culturalism, Colonialism and the Politics of Knowing by Cathryn McConaghy ISBN 1-876682-02-7; $59.50 + p&h
Reflecting on Racial Attitudes: After 24 years revisiting Student Teachers’ attitudes towards Aborigines by Clarence Alfred Diefenbach ISBN 1-876682-48-5; $24.50 + p&h Patrons & Riders: Conflicting Roles & Hidden Objectives in an Aboriginal Development Programme by Peter Willis ISBN 1-876682-40-X; PTY $55.00 + p&h management LTD
e C ontent
Volume 28, Issue 1–2, April 2008
CN
xi
CNJ 28_1_2_internal.qxd
14/07/2008
12:22 PM
Page xii
C A L L F O R PA P E R S : 2 0 0 9 & 2 0 1 0 A d v a n c e s i n C o n t e m p o r a r y N u r s i n g S e r i e s ISSN 1832-9861 A DVANCES
IN
C ONTEMPORARY N URSE E DUCATION
A special issue of Contemporary Nurse, Volume 32 Issue 1–2, publishing April 2009 Edited by: Debra Jackson and Michael Clinton Deadline for manuscripts: 30 September 2008 Information: www.contemporarynurse.com/archives/vol/32/issue/1-2/call/
A DVANCES
IN
C ONTEMPORARY N URSING
AND
G ENDER
A special issue of Contemporary Nurse, Volume 33 Issue 2, publishing October 2009 Edited by: Paula McGee and Kim Walker Deadline for manuscripts: 15 December 2008 Information: www.contemporarynurse.com/archives/vol/33/issue/2/call/
A DVANCES
IN
C ONTEMPORARY M ENTAL H EALTH N URSING , S ECOND E DITION
A special issue of Contemporary Nurse, Volume 34 Issue 1, publishing December 2009 Edited by: Nicholas Procter and Angela Frederick Amar Deadline for manuscripts: 2 March 2009 Information: www.contemporarynurse.com/archives/vol/34/issue/1/call/
A DVANCES
IN
C ONTEMPORARY M ODELING
OF
C LINICAL N URSING C ARE
A special issue of Contemporary Nurse, Volume 35 Issue 1, publishing April 2010 Edited by: Mary Chiarella and Judith Lathlean Deadline for manuscripts: 30 April 2009 Information: www.contemporarynurse.com/archives/vol/35/issue/1/call/ Author Guidelines are available from www.contemporarynurse.com
B O X E D
S E T S
A V A I L A B L E
Advances in Contemporary Nursing Series ISSN 1832-9861 – 4 volumes per annum from 2006 2009:
2007:
• Volume 13: Advances in Contemporary Nurse Education
• Volume 5: Advances in Contemporary Indigenous Health Care – ISBN 978-0-9750436-9-1
• Volume 14: Advances in Contemporary Nursing and Gender • Volume 15: Advances in Contemporary Mental Health Nursing, 2nd edn • Volume 16: Advances in Contemporary Modeling of Clinical Nursing Care
• Volume 6: Advances in Contemporary Community and Family Health Care – ISBN 978-0-9757710-2-0 • Volume 7: Advances in Contemporary Nurse Recruitment and Retention – ISBN 978-0-9757710-0-6
2008:
• Volume 8: Advances in Contemporary General Practice Nursing – ISBN 978-0-9757710-3-7
• Volume 9: Advances in Contemporary Aged Care – ISBN 978-0-9757710-1-3
2006:
• Volume 10: Advances in Contemporary Palliative and Supportive Care – ISBN 978-0-9757710-4-4 • Volume 11: Advances in Contemporary Transcultural Nursing, 2nd edn – ISBN 978-0-9757710-5-1 • Volume 12: Advances in Contemporary Nursing History & Midwifery in Australia – ISBN 978-0-9775742-8-5
• Volume 1: Advances in Contemporary Transcultural Nursing – ISBN 978-0-9750436-1-5 • Volume 2: Advances in Contemporary Child and Family Health Care – ISBN 978-0-9750436-3-9 • Volume 3: Advances in Contemporary Mental Health Nursing – ISBN 978-0-9759436-8-4 • Volume 4: Advances in Contemporary Nursing and Interpersonal Violence – ISBN 978-0-9750436-6-0
eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected] www.e-contentmanagement.com
xii
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
CN T
12:22 PM
Page 1
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 1–2.
EDITORIAL The state of transcultural nursing global leadership and education
LINDA J LUNA
JUNE MILLER
International Nurse Consultant School of Nursing University of Phoenix Nashville TN, USA
President School of Nursing Johns Hopkins University Baltimore MD, USA
he scholarly articles presented in this section reflect the current state of global transcultural nursing leadership, as well as the progress made in fostering cultural competence through transcultural nursing education.Transcultural nursing can be traced back to the early years, over a half century ago, when Dr Madeleine Leininger first began exploring the relationship between nursing and anthropology (Leininger 1970).Through her pioneering theoretical work, we first started using the term ‘transcultural’, to mean ‘across all world nations’. We have since developed into our own discipline of transcultural nursing, boasting of our unique knowledge base within the discipline of nursing. Leadership has emerged through the years, with the establishment of the Transcultural Nursing Society in the United States in 1975, and the 1994 establishment of the Transcultural Nursing Society in Australia through the Royal College of Nursing, Australia. Both organisations, through collaboration and individual efforts, have provided leadership for the expanding discipline, to include the hosting of annual international conferences, the development of policy and position statements, and the encouragement and show-
casing of important research focusing on unique culture care perspectives. Bryant and colleagues (2008) provide an excellent evolutionary perspective of the role the Royal College of Nursing, Australia (RCNA) has played in supporting the growth and development of transcultural nursing in Australia. The official recognition of transcultural nursing as a distinct society in 1994 firmly established the importance of discovering care from a cultural perspective in a multicultural society such as Australia. The article by Andrews (2008) highlights the global nature of transcultural nursing and identifies many Australian nurse leaders who have been visionaries in establishing culturally relevant nursing practice. As a result of the scholarly work by Australian transcultural nurse leaders, there is now a significant body of knowledge in nursing that is useful in practice, education and research around the globe. As much as we would like to think all of this progress translates into effective education programs for practicing nurses and faculty, read the contemporary articles before you say otherwise. We are still only beginning to understand how
Volume 28, Issue 1–2, April 2008
CN
1
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:22 PM
Page 2
Linda J Luna and June Miller
we can provide the critical learning environment for students to grasp the key components of transcultural nursing, and to then evaluate the effectiveness of our programs. Lynette Raymond, of the University of Notre Dame, Sydney Australia (2008), shares with us a detailed BN curriculum approach, including several required courses in TCN, and the introduction of a variety of conceptual models.This very specific curriculum focus, designed from extensive literature review of research relevant to Australia, includes plans for evaluation one year after graduation.We look forward to the results. On the other hand, we are faced with two research studies that declare we are not finding positive results in many of our attempts to evaluate cultural competency in undergraduate programs in the United States. Mixer (2008) describes a gap in faculty knowledge, and therefore limited ability to provide the context of culture care for student learning. KardongEdgren and Camphina-Bacote (2008) present a study indicating that regardless of approach, by graduation many students are not scoring beyond cultural awareness in scales measuring cultural competence. These findings are reminiscent of the situation with measuring critical thinking as an outcome measure of baccalaureate schools of nursing. Like critical thinking, we know that cultural competence is an important outcome of baccalaureate education, but how do we measure it? It seems that many of us who have made transcultural nursing our life’s work, especially exploring theory and research, need now refocus our leadership skills to direct our attention to insuring that students and clinicians are nurtured in culture care principles.We must be creative in designing clinical cultural immersion experiences, faculty workshops, and evaluation tools, both qualitative and quantitative to measure the effectiveness of our cultural competence programs. The discipline of transcultural nursing is well grounded in our scholarly theoretical 2
CN
Volume 28, Issue 1–2, April 2008
work and our extensive worldwide research. Our leaders share important findings with each other through international conferences and scholarly journals.We talk and write extensively about cultural competence for health care professionals. However, the question is whether we are actually successful at disseminating that knowledge into clinical practice. Should we now direct our focus away from the macro worldwide, theoretical stance and toward a micro focus on each individual student nurse, to insure they are provided with opportunities for learning the process of cultural competence? TCNS International is in the final stages of launching its new certification process, to include an extensive curriculum which will be available to nurses worldwide. Perhaps, combined with intensive cultural immersion experiences and more faculty opportunity for in-depth learning about teaching concepts of TCN, we can move forward.We need to continue our pioneering efforts to expand our leadership in creative ways to answer the important questions raised in the writings of these well known scholars of transcultural nursing. The future of health care depends on the work of those at the bedside in every cultural context.
References
Andrews MM (2008) Commentary: Global leadership in transcultural practice, education and research, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 13–16. Bryant RB, Foley ER and Percival EC (2008) The role of RCNA in promoting transcultural nursing as a discipline of study, research, practice and management in Australia, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 3–11. Kardong-Edgren S and Campinha-Bacote J (2008) Cultural competency of graduating US Bachelor of Science nursing students, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 37–44. Leininger M (1970). Nursing and Anthropology:Two worlds to blend. John Wiley & Sons: New York. Mixer SJ (2008) Use of the culture care theory and ethnonursing method to discover how nursing faculty teach culture care, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 23–36. Raymond LM (2008) Exemplar: Developing a new Bachelor of Nursing course responsive to Australia’s culturally diverse community, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 17–22.
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 3
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 3–11.
The role of RCNA in promoting transcultural nursing as a discipline of study, research, practice and management in Australia ABSTRACT Key Words Royal College of Nursing, Australia; transcultural nursing; national network; Transcultural Nursing Society; multicultural; Indigenous; position statements; culturally diverse; care needs
Royal College of Nursing, Australia has supported the development and growth of transcultural nursing in Australia for well over a decade.The College’s leadership role has been evident on a number of fronts with events, publications and national networking opportunities for nurses who share a passion for furthering the principles and practice of transcultural nursing. This paper traces the journey of transcultural nursing in Australia from the perspective of the College, beginning with its role in forming the Transcultural Nursing Society in the 1990s.Achievements are highlighted, as well as continuing work over the intervening years, demonstrating the involvement and leadership of the College in Australia, in this important area of nursing practice. With increasing complexity in the ethnic profile of Australia’s society, it is of ongoing relevance for the College to promote transcultural nursing as a discipline of study, research, practice and management in this country. Received 15 July 2007
Accepted 16 October 2007
CN
ROSEMARY B BRYANT
ELIZABETH R FOLEY
ELIZABETH C PERCIVAL AM
Executive Director Royal College of Nursing, Australia Canberra, Australia
Director Policy Royal College of Nursing, Australia Canberra, Australia
Previous Executive Director Royal College of Nursing, Australia Canberra, Australia
Volume 28, Issue 1–2, April 2008
CN
3
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 4
Rosemary B Bryant, Elizabeth R Foley and Elizabeth C Percival
BACKGROUND
I
n 1994, Royal College of Nursing, Australia, with support from members, established a Transcultural Nursing Society. This move was indicative of nursing trends at the time relating to the growing interest in, and commitment to transcultural nursing education, research, management and practice.The Society reflected the College’s preparedness to take a leadership role in forming a national group of nurses interested in fostering and promoting culturally relevant nursing care practice. In welcoming transcultural nursing, the College was the first nursing organisation to embrace this concept of care and give transcultural nursing a firm place as a discipline within the profession. Indeed the College remains the only national nursing organisation in Australia to support transcultural nursing with a Transcultural National Network for its members. This paper will trace the journey of transcultural nursing in Australia from the perspective of the College, beginning with the formation of the Transcultural Nursing Society, highlighting achievements and continuing work over more than a decade of involvement and leadership in this important area of nursing practice.
DEVELOPMENT OF TRANSCULTURAL NURSING IN AUSTRALIA In the early 1990s the College was creating specialty network groups for members – called Societies – to facilitate sharing of ideas, research, innovations in practice and education models, across a range of interest areas.The aim of the Societies was also to provide a structure of programs which would ‘foster professional development of members, individuals and the profession’ (RCNA Archive File 863a 1994–96). Importantly the Societies would be ‘a mechanism for identifying and drawing upon the specific interests and expertise of members through whom the work of the College could be furthered’. These Societies included: Research, Education, Gerontology, Clinical Practice, Legal 4
CN
Volume 28, Issue 1–2, April 2008
Issues, Ethics, and Transcultural Nursing. Over time there were changes in the nature and purpose of these groups with some rolling into other groups and new groupings being formed. Today there are fourteen such groups, which are now termed National Networks. Having formed in April 1994, the Transcultural Nursing Society was one of the initial Societies, and resulted from strong representation from members. Dr Akram Omeri FRCNA was a prime instigator of the Society and the first Chair of the initial management group, and has remained the staunchest advocate for this group over the years. In addition, Dr Omeri has been an advisor to the College on issues relating to transcultural nursing, and continues in this role to the present time. Initial canvassing of the College membership elicited overwhelming support for the establishment of a Transcultural Nursing Society. The comments from members were reflected in a letter from Olga Kanitsaki FRCNA of 5 October 1994 (RCNA Archive File 863b 1994–96) where she says of the College that ‘It clearly illustrates its professional leadership, and responsibility to its members, and society at large’. An interim Management Committee was established in early 1995, with elections for the ongoing Management Committee in May of that year. In an interview at the time Dr Omeri claimed that ‘The College’s support was official recognition of the significance of transcultural nursing’ (Omeri 1995). In the same article Dr Omeri described transcultural nursing as ‘the comparative study of cultures and their caring practices’. Referring to Dr Leininger’s work, she also said that ‘transcultural nursing moved beyond ethnicity, examining issues relating to race, class, gender, religion, sexuality and age, identifying differences and similarities within cultures – the goal being to provide culturally specific nursing care’ (Leininger 1989, 1997). With these views forming a shared understanding within the new Society for transcultural nursing in Australia, the group aimed: to act
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 5
The role of RCNA in promoting transcultural nursing as a discipline in an advisory capacity on matters relating to transcultural nursing primarily to the College but also to external policy, education and health care groups; to facilitate the dissemination of transcultural nursing information to stimulate interest and effective nursing care practices; and to promote a positive image of transcultural nursing to the profession and governments; and enrich the knowledge and practice of Australian nurses in transcultural nursing. Benefits of membership to the Society were identified as: • Support to foster your interest in transcultural nursing; • A part to play in the development of national awareness about the nursing profession and its contribution to society; • Networking opportunities to share your interest with like-minded colleagues; • The chance to take an active role in the organisation of Society activities. (RCNA Archive File 863c 1994–96) Over the next couple of years, the Society set about determining strategies for achieving the articulated aims, through a variety of formats at national and state/territory level via the College Chapters. In addition to input from the members of the Society, advice was also sought from a range of nurse leaders, especially those within the Australian Indigenous community. The latter group of leaders included Dr Sally Goold OAM FRCNA (now Chair of the Congress of Aboriginal and Torres Strait Islander Nurses), Lowitja O’Donoghue Hon FRCNA (former Chair of the Aboriginal and Torres Strait Islander Commission), and Dr Gracelyn Smallwood (adviser on Indigenous Health).Their engagement was requested to provide advice on specific contributions from Aboriginal and Torres Strait Islander nurses to the Transcultural Nursing Society. Dr Goold continues as an advisor to the College on Indigenous matters, particularly relating to health care practices and services and nursing education.
CN
WORK OF THE SOCIETY (NOW NETWORK) In order not to lose the momentum of the newly formed Society, a number of actions were taken over the first year of operation resulting in publications, meetings, and conferences. All of these aimed to further the work of the College in strengthening the concept of transcultural nursing within the profession. These are outlined below and have formed the basis for ongoing work.
Newsletter/bulletin A quarterly newsletter titled Transcultural Nursing Society Bulletin was commenced to share information on transcultural nursing issues relating to education, research, management and clinical practice. Members from each State and Territory were identified as key people for gathering relevant material on the practice of transcultural nursing ideologies as these were implemented in their local areas. In the first edition of the Transcultural Nursing Society Bulletin (published in October 1995) the then Executive Director of the College, Elizabeth Percival AM FRCNA, greeted the society members on the front page with the following message: I am delighted that Royal College of Nursing, Australia has been able to facilitate the establishment of the Transcultural Nursing Society.Within our health system nurses are the main point of contact for all who find themselves in hospital or are consumers of health care in other ways. Nurses bring scientific and technical skills and a caring dimension to their practice. These, however, would come to nothing if they operated without an understanding of the cultural frameworks and cultural dimensions of our society. Australia’s population is made up of many cultures.There are cultures of our oldest inhabitants; cultures of those who migrated from English speaking countries in the first
Volume 28, Issue 1–2, April 2008
CN
5
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 6
Rosemary B Bryant, Elizabeth R Foley and Elizabeth C Percival century or so after colonisation, and cultures of the innumerable groups who have arrived on our shores in the last half century. In all these cultures, socioeconomic status, class, occupational status, age, gender and ethnicity are related. When nurses interact with patients their values, their expectations, their perceptions, and their communication skills are central to the healing process. Acquiring knowledge about cultures, knowing how they impact on individuals’ health care outcomes is essential for nurses. Through the work of the College’s Transcultural Nursing Society cultural issues will be firmly placed on the nursing agenda, and patient care can only be strengthened and health outcomes improved as a consequence of the Society’s activities. I welcome the establishment of this Society and wish you well for meeting the challenges of the tasks ahead. (Percival 1995)
This first edition newsletter also carried a story of the dissolution of the Transcultural Health Care Council (THCC) Inc which had been founded ten years previously in the State of Victoria. In a demonstration of faith in the newly establishing Transcultural Nursing Society, the THCC decided to disband, with many of its members moving into membership of the College (some of course were already College members). While levels of enthusiasm have waxed and waned over the years, the now titled Transcultural National Network continues a newsletter today, within the College’s publication for Networks and Chapters – Connections.Through this newsletter, College members of the Transcultural National Network are encouraged to continue the important foundation work of the Transcultural Nursing Society by ‘promoting tolerance towards equality of practice of our culturally and linguistically diverse society, promoting the health and well-being of all, includ6
CN
Volume 28, Issue 1–2, April 2008
ing marginalised populations and refugees’ (Omeri 2004 ). Members share experiences in clinical practice and management working with culturally diverse health care groups, as well as disseminate research work which they are currently involved in or have undertaken.
Professional development series In the mid to late 1990s the College was producing a series of books called the Professional Development Series. While these had a price tag attached the cost was largely underwritten by the College in fulfilling its objectives to contribute to nurses continuing professional development. A significant demonstration of the College’s leadership in the area of transcultural nursing was the commissioning of a book in this series titled Transcultural Nursing in Multicultural Australia. The significance of the book was that this was the first collection of writings in transcultural nursing edited and authored by Australian nurses in the context of Australia. The content of the book addressed the significance of transcultural nursing in nursing education and research; community and mental health nursing; primary health care nursing; and examined transcultural nursing from the consumer perspective including those of Aborigines. In her ‘Foreword’ remarks in Transcultural Nursing in Multicultural Australia, Elizabeth Percival AM FRCNA outlines the importance of this text to Australian nurses: This volume comes at a time in Australia’s history when all members of our community are reassessing their understanding and acceptance of different cultures. More than forty percent of Australia’s population are people who are post-war immigrants or children of post-war immigrants. As a result of this population structure nurses have been presented with practice challenges. In many instances they have not been adequately provided with the opportunity to learn about
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 7
The role of RCNA in promoting transcultural nursing as a discipline
CN
other cultures and this has left deficits in the Education for Aboriginal and Torres Strait Islander Peoples (RCNA 2003b). These statements were delivery of comprehensive nursing care. (Omeri & Cameron-Traub 1996: 7–8) originally developed in 1998, and serve as ongoing guidance documents to members and The book has proven immensely popular with other nurses, as well as being advocacy tools in Australian nurses and remains available to be working with policy makers in the health and downloaded and printed (at no cost) for mem- education arenas. In the statement on health services the Colbers and other nurses, from the College’s weblege maintains that ‘in order to provide primary site: www.rcna.org.au.While now having been written over a decade ago the material in this health care, that is acceptable and meaningful book is of continuing relevance to nurses in to Indigenous peoples, the provision of culturally safe health services is necessary’ (RCNA Australia today. 2003a). The College has needed to reinforce this principle when dealing with agencies who Position statements The College’s position statement on Nursing have wanted to import nurses from entirely difin a Culturally Diverse Australia (RCNA 2000a) ferent cultures, to immediately work in Indigereflects its commitment to raising awareness nous communities, without any knowledge of amongst the membership and the nursing com- the Australian health care system let alone spemunity in general, of the need for transcultural cific cultural issues. The College’s statement on nursing educaknowledge and understanding to enhance nurstion contends that ‘the recruitment and retening practice. The statement highlights the fact that cultural differences can become barriers to tion of Aboriginal and Torres Strait Islander equal access to health care services particularly peoples as both registered and enrolled nurses if these differences are seen as being inferior to is essential to provide an increased level of the dominant (Anglo-Saxon-Celtic) culture in health care to Aboriginal and Torres Strait Australia. The statement declares the College’s Islander peoples’ (RCNA 2003b). The College belief that ‘Nursing practice should be culturally has put the principles espoused in this statement inclusive, appropriate and meaningful to specific into action by successfully tendering for, and cultures to meet the diverse and different needs administering the Australian Government Puggy of the Australian community’ (RCNA 2000a). Hunter Memorial Scholarships for Indigenous Of critical importance is the rationale statement Australians intending to undertake studies in which reads: ‘In a culturally diverse community, medicine, nursing, dental, Aboriginal Health such as Australia’s, the aim of providing cultur- Worker, management and mental health discially congruent and empowering health care for plines. This funding provides essential support its citizens, requires a shift from a monocultural for Indigenous people to achieve qualifications focus to a critical transcultural focus in nursing in health disciplines so that they in turn can practice and the provision of nursing services’. influence more culturally aware health care for The College’s statement, originally released in their communities.They may either practice in 1998, is an integral document in its ongoing specific Indigenous health services or in mainwork to embed concepts of transcultural nurs- stream services accessed by Indigenous peoples. Indigenous students in receipt of any of the ing into nursing practice. Two College position statements address Australian Government nursing scholarships issues of importance to Indigenous Australian’s, administered by the College are also assisted namely: Health Services for Aboriginal and Torres throughout their studies through a range of supStrait Islander Peoples (RCNA 2003a) and Nursing port measures, including a mentor program.
Volume 28, Issue 1–2, April 2008
CN
7
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 8
Rosemary B Bryant, Elizabeth R Foley and Elizabeth C Percival
The foregoing three identified position statements reflect the College’s commitment to transcultural nursing by demonstrating how it has been proactive in promoting culturally appropriate nursing and health care to Indigenous people, as well as to the over 200 culturally diverse groups who have made Australia home. An examination of the statements will also reveal the College’s commitment to promoting the inclusion of studies on Indigenous and transcultural care issues within undergraduate and postgraduate programs for nurses. These position statements are available on the College website and form valuable guides to College members and other nurses relating to their practice in a multicultural environment. The statements are equally pertinent to nurses in metropolitan, regional, rural and remote areas of Australia. They are also used to articulate the College’s position when making policy submissions to governments. In addition to the articulation of its own position, the College also provides input to the development of statements by other organisations, such as the International Council of Nurses’ statement on cultural and linguistic competence, and the Australian Nursing and Midwifery Council’s statement on the inclusion of health and cultural issues for Aboriginal and Torres Strait Islander People in programs in Australia leading to registration or enrolment as nurses.
Conferences/collaboration with Transcultural Nursing Society Global In 1997 the College through its Transcultural Nursing Society, collaborated within Australia with Sydney University, University of Technology, Sydney and with support from University of Western Sydney, and internationally with lead members of the Transcultural Nursing (TCN) Society Global, to host the Transcultural Nursing: New Pathways, New Ventures education workshop and conference.The conference pro8
CN
Volume 28, Issue 1–2, April 2008
vided a forum for scholarly debate of transcultural nursing issues through: • Exploration of contemporary issues, myths and forces that have facilitated or impeded the development of transcultural nursing in Australia and worldwide; • Consideration of the future of transcultural nursing in the 21st Century in advancing education, research and practice in Australia and worldwide; • Providing an overview of strategies utilised in teaching transcultural nursing in undergraduate and graduate programs; • Exchange on the development of innovative policy, education, research and practice strategies in respect to transcultural nursing; and • An opportunity to promote the College’s Transcultural Nursing Society. (RCNA 1997) Professor Madeleine Leininger (founder of the field of transcultural nursing) and Dr Marilyn McFarland, both from the United States of America (USA) TCN Society Global, took lead roles in the event, conducting a pre-conference workshop and then addressing the conference delegates through the keynote paper and other presentations. Other speakers came from all states and territories of Australia, New Zealand, Saudi Arabia, and the USA. A couple of participants wrote to the College saying that the conference had stimulated a ‘catalyst for change’ and was the ‘impetus for many of us to realise that perhaps we are close to the time when Australian nursing will name for itself what is relevant in this important field of nursing. They said the conference ‘created an opportunity for ongoing debate to be informed by four decades of pioneering work by Professor Madeleine Leininger in transcultural nursing’.They also felt that the New Zealanders had given examples of how they had developed pathways for nurses practising in colonised nations and that Australian nurses should learn from these innovations. Essentially these delegates considered that ‘together, in partnership
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 9
The role of RCNA in promoting transcultural nursing as a discipline with those from culturally diverse groups, we should be raising the questions and issues that need to be asked to arrive at a unique Australian perspective on cross cultural nursing’ (RCNA Archive File 760 1997–99). During the late 1990s links were being forged with the TCN Society Global which was keen to develop a collaborative partnership.Thus it was that three years after the first conference a second conference was held in 2000, jointly hosted by the TCN Society Global, the College and its Transcultural Nursing Society.Titled International Transcultural Nursing: Leading into the new millennium (RCNA 2000b), this event was also a resounding success, with keynote speakers being Emeritus Professor Madeleine Leininger, USA, Ms Irihapeti Ramsden, New Zealand and Dr Sally Goold OAM FRCNA, Australia. In what should be interpreted as a recognition of the College’s leading role in nursing in Australia, and specifically in transcultural nursing, the conference was opened by Senator The Honourable John Herron, then Federal Minister for Aboriginal and Torres Strait Islander Affairs. The conference attracted speakers and delegates from the USA, New Zealand, South Africa, the United Kingdom, Sweden, Botswana and across Australia.This international audience enabled Australian nurses to showcase work being undertaken across clinical, education, management, research and education spheres, in relation to transcultural nursing in our country. It also gave an opportunity to highlight differences in our cultural profile from their countries, which impacted on the approaches needed to provide culturally safe nursing care and challenges faced by Australian nurses. In recognition of the support and advice given by Dr Madeleine Leininger over the earlier years of the development of the Transcultural Nursing Society, in addition to her work internationally, the College presented her at this conference with our prestigious International Achievement Award. The College has taken seriously over the
CN
years its lead role in hosting major events such as those described above, through which networking on transcultural nursing has been facilitated, as well as forums that occur around the country to assist nurses on a local level to engage in similar discussions. The College’s annual conference, no matter the central theme, always promotes and contains papers pertaining to some aspect of care in a multicultural society. Most recently the College’s annual conference in Sydney (11–14 July 2007), Illuminating Nursing, provided an opportunity for speakers from all States and Territories as well as overseas visitors, to give papers on nursing care in culturally diverse environments. In particular, three of the keynote speakers presented thought provoking papers on issues relating to culturally diverse care: preparedness of nurses across the globe in disaster situations – Dr Hiroko Minami (Japan); critical mental health care needs in the Pacific Islands – Dr Frances Hughes (New Zealand); and the appalling inequality of health care services in Indigenous communities in Australia – Dr Sally Goold OAM FRCNA (Australia).
Policy work The College’s policy development and analysis program has covered over the years an extensive array of issues relating to health and aged care in general and professional nursing issues. The program includes (but is not limited to) the development of position statements, submissions and responses to draft government policy, representation on committees, advocacy for the profession and health and aged care, and collaborative work with other nursing or health professional groups. Across any of these activities there are opportunities for raising matters relating to transcultural care.While some aspects of this policy work have been referred to in the foregoing paper, a perusal of the policy work undertaken since the start of this decade alone, reveals input to specific issues.The following is a snapshot of some of these: Aboriginal and Torres Strait Islander health workforce strategic Volume 28, Issue 1–2, April 2008
CN
9
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 10
Rosemary B Bryant, Elizabeth R Foley and Elizabeth C Percival
framework; Aboriginal and Torres Strait Islander health worker training; guidelines for health related research amongst Aboriginal and Torres Strait Islander peoples; development of a national policy on multicultural mental health; the health of children in immigration detention; and health services for migrants, refugees, displaced and detained persons. The latest census data of Australia’s citizens, published by the Australian Bureau of Statistics (2006) states that around thirty per cent of the population of almost twenty million people, were born overseas.While there are some predominant countries of origin for Australians born overseas (or their parents) such as the United Kingdom, Europe, Mediterranean countries and Asia, there is an increasing number of people from a wider range of countries.This has occurred over recent years with Australia’s policies on bringing in refugees through its Humanitarian Program (DI&C 2007), which brings in many thousands of people in need to Australia each year. The past decade has seen an increasing number of people from Middle Eastern countries and African countries.The health vulnerabilities of some of these newer arrivals to this country are presenting the nursing profession in Australia with new and different cultural challenges. There are obvious implications which the College sees of the multicultural nature of our society for nursing practice, research and development. It forces us to institute systems which facilitate different models of care (and indeed actively explore different models rather than just a more passive adoption of same) and give more than lip service to individualised care. In some cases the research undertaken by nurses may actually lead to new physical structures needing to be considered for health care facilities and aged care residences, as well as care practices. Despite years now of having large populations of different ethnic groups within Australia, the mainstream health care system is still largely geared to an homogenous, Anglo10
CN
Volume 28, Issue 1–2, April 2008
Saxon consumer base.The College works within its membership, and in collaboration with other nursing groups, to promote inclusion of transcultural aspects in education programs; development and implementation of health and aged care policies which include attention to culturally sensitive practices and infrastructure; and encouragement of research which will demonstrate the benefits to health outcomes of culturally competent and respectful care.
CONCLUDING COMMENTS Royal College of Nursing, Australia has been privileged to have been involved with the growth of transcultural nursing in Australia since the inception of the College’s Transcultural Nursing Society in the early 1990s, to present day. With members’ support the College took the initiative in providing a vehicle through which nurses who shared a passion for transcultural nursing could foster and promote culturally relevant nursing care practice. A continuing record of work undertaken over the years to further the concepts of transcultural nursing can be seen in the publications, position statements and policy work of the College.The College’s National Network for Transcultural Nursing perpetuates the values of the original Society and continues to make transcultural nursing a positive reality as a discipline in study, research, practice and management in Australia. The College salutes those members whose efforts and dedication have contributed to its ability to be the lead organisation in promoting transcultural nursing in this country. The College is continuing its commitment to assist nurses in their ability to respond effectively to all new citizens to our country and to better meet the health and nursing care needs of all people in our multicultural society.
Acknowledgements These go to Karen Dansey for assistance with locating material from RCNAs archival collection; and Monique Brouwer – both RCNA staff.
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 11
The role of RCNA in promoting transcultural nursing as a discipline References Australian Bureau of Statistics Census Data (2006) accessed at http://www.abs.gov.au/websitedbs /d3310114.nsf/home/Census+data on 14 June 2007. Department of Immigration and Citizenship (DI&C) (2007) accessed at www.immi.gov.au/immigra tion.htm on 14 June 2007. Leininger MM (1989) CLASSIC-Transcultural Nursing: QuoVadis (Where Goeth the Field). Journal of Transcultural Nursing 1: 33–45. Leininger MM (1997) Transcultural nursing: A scientific and humanistic care discipline. Journal of Transcultural Nursing 8: 54–55. Omeri A (1995) A bedside manner to transcend borders. University of Sydney News 27(9) 26 April. Omeri A (1996) Transcultural nursing care values, and beliefs of Iranian immigrants in NSW Australia. Unpublished doctoral thesis,The University of Sydney Australia. Omeri A and Cameron-Traub E (Eds) (1996) Transcultural Nursing in Multicultural Australia. Royal College of Nursing, Australia. Accessed at www.rcna.org.au on 21 May 2008. Omeri A (1998) Course charts cultural shift. Nursing Review: 23. Omeri A (1998) Nursing lecturer wins top international award. The University of Sydney News 12 (November): 5. Omeri A (2004) Transcultural nursing:Where from here! Connections 7: 35. Omeri A (2005) Omeri wins transcultural nursing scholar award. Nursing Review December 2005.
N O W
CN
Percival E (1995) Royal College of Nursing,Australia, Transcultural Nursing Society Bulletin 1 (October). RCNA Resources, Canberra. Royal College of Nursing, Australia (2000a) Position Statement: Nursing in a Culturally Diverse Australia accessed at www.rcna.org.au on 6 June 2007. Royal College of Nursing, Australia (2003a) Position Statement: Health Services for Aboriginal and Torres Strait Islander Peoples accessed at www.rcna.org.au on 8 June 2007. Royal College of Nursing, Australia (2003b) Position Statement: Nursing Education for Aboriginal and Torres Strait Islander Peoples accessed at www.rcna.org.au on 8 June 2007. Royal College of Nursing, Australia (1997) Transcultural Nursing: New Pathways, New Ventures conference abstract. RCNA Resources, Canberra. Royal College of Nursing, Australia (2000b) International Transcultural Nursing: Leading into the New Millennium. RCNA Resources, Canberra. Royal College of Nursing, Australia (RCNA) Archive File 760 (1997–99). Fax 17/12/97 from Toni Dowd, RCNA Archive, Canberra. Royal College of Nursing, Australia (RCNA) Archive File 863a (1994–96). Societies Brochure, RCNA Archive, Canberra. Royal College of Nursing, Australia (RCNA) Archive File 863b (1994–96). Letter from Dr Olga Kanitsaki 5 October 1994, RCNA Archive, Canberra. Royal College of Nursing, Australia (RCNA) Archive File 863c (1994–96).Transcultural Nursing Society Brochure, RCNA Archive, Canberra.
A V A I L A B L E
I N O UR O WN R IGHT: B LACK A USTRALIAN N URSES ’ S TORIES Edited by Sally Goold OAM (Senior Australian of the Year 2006) and Kerrynne Liddle ISBN 978-0-9757422-2-8; viii +120 pages; s/c; 2005 ‘This book provides a powerful catalyst for questioning and calling into question the taken-for-granted humanity in us all.’ — Olga Kanitsaki AM ‘This book is a celebration of Indigenous Australian nurses and the difficulties they have overcome. It is not about directing blame or guilt, but rather a commemoration of their achievements and an inspiration for all Indigenous peoples.’ — Sally Goold OAM eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected]; www.e-contentmanagement.com
e C ontent
PTY
management LTD
Volume 28, Issue 1–2, April 2008
CN
11
CNJ 28_1_2_internal.qxd
30/07/2008
9:46 PM
Page 12
C A L L S F O R PA P E R S : 2009 & 2010 I N T E R N AT I O N A L J O U R N A L
OF
MULTIPLE RESEARCH APPROACHES ISSN 1834 0806
w w w. i j m r a . c o m
Editor-in-Chief: Professor Carol Grbich, Flinders University School of Medicine
T EACHING M IXED M ETHODOLOGIES Special issue of the International Journal of Multiple Research Approaches, volume 3 issue 3, November 2009 Guest editors: Nancy L Leech (Colorado), Anthony Onwuegbuzie (Texas), Thomas Hansson (Denmark) and Priscilla Robinson (Australia) Deadline for manuscripts: 15 December 2008 Information: http://mra.e-contentmanagement.com/archives/vol/3/issue/3/call/
U SING V IDEO
IN
S OCIAL S CIENCES
AND
H EALTH R ESEARCH
Special issue of International Journal of Multiple Research Approaches, volume 3 issue 2, June 2009 Advisory Editors: Rick Iedema, University of Technology, Sydney; Christian Heath, Kings College, London; and Alexandra Juhasz, Pitzer College, Claremont CA, USA Guest Editors: Rowena Forsyth, University of New South Wales; Katherine Carroll, University of Technology, Sydney; and Paul Reitano, University of New England, Australia Deadline for manuscripts: 15 September 2008 Information: http://mra.e-contentmanagement.com/archives/vol/3/issue/2/call/
M ULTIPLE M ETHODS
FOR
N OVICE R ESEARCHERS
Special issue of International Journal of Multiple Research Approaches, volume 3 issue 1, 2008 Edited by Elizabeth Waters (Melbourne), David Este (Calgary), Alicia O’Cathain (Sheffield) and Kathleen MT Collins (Arkansas) Deadline for manuscripts: Closed Information: http://mra.e-contentmanagement.com/archives/vol/3/issue/1/call/ Submissions following Author Guidelines on the journal website may be addressed to:
[email protected]
R E C E N T
S P E C I A L
I S S U E S
U SING Q UALITATIVE AND Q UANTITATIVE M ETHODS IN D EVELOPMENT P OLICY: Q- SQUARED D ECISION M AKING IN THE C ASE OF P OVERTY A NALYSIS A special issue of International Journal of Multiple Research Approaches, volume 2 issue 2 ISBN 978-1-9213482-6-6; iv + 92 pages; s/c; October 2008 Edited by Paul Shaffer (University of Toronto), Ravi Kanbur (Cornell University), Ellen Bortei-Doku Aryeetey (University of Ghana) and Nguyen Thang (Vietnam Academy of Social Sciences)
C OMPUTER A SSISTED M ULTIPLE
AND
B LENDED R ESEARCH M ETHODS
A special issue of International Journal of Multiple Research Approaches, volume 2 issue 1 ISBN 978-1-921348-04-4; ii + 126 pages; s/c; June 2008 Edited by Eugenio De Gregorio (Sapienza University of Rome) and Francesco Arcidiacono (University of Neuchâtel) with an epilogue by Pat Bazeley (Research Support P/L and ACU)
C ONDUCTING L ONGITUDINAL R ESEARCH : P RACTICAL LESSONS FROM THE A USTRALIAN L ONGITUDINAL S TUDY ON W OMEN ’ S H EALTH A special issue of International Journal of Multiple Research Approaches, volume 1 issue 2 ISBN 978-0-9775742-9-2; ii + 134 pages; s/c; December 2007 Edited by Deborah Loxton, Julie Byles, Annette Dobson and Wendy Brown eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected] www.e-contentmanagement.com
12
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 13
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 13–16.
CN
C O M M E N T A R Y Global leadership in transcultural practice, education and research Key Words nurse leadership; transcultural nursing; nursing history; cultural care diversity and universality theory; Leininger; cultural competence
CN
MARGARET M ANDREWS
Received 20 February 2008 Accepted 20 March 2008
I
t is amazing what some women and men dare to do with their ideas in many places in the world. Creative thinking and actions are what the world needs most.Transcultural nursing has been an example of these attributes.While taking new actions may be troublesome to some people, yet new actions and new ideas can lead to a wealth of new knowledge and new ways to serve people.Transcultural nurses have taken such actions and are transforming nursing and health care in many places in the world. Leininger (2007: 1) Derived from Latin roots leadership refers to the act of guiding the course or direction; preceding or introducing something by going first. During the past six decades, transcultural nursing’s foundress, United States-born nurse-anthropologist Dr Madeleine M. Leininger and other transcultural nursing leaders from Australia and elsewhere in the world have provided leadership in establishing transcultural nursing as a formal area of academic study and practice around the world. Since its initial conception in the 1950s to its formal creation as a specialty and new discipline within the nursing profession in subse-
Director/Professor of Nursing University of Michigan Flint MI, USA
quent years, a substantial and important body of transcultural knowledge, theory, and research has been generated by nurse scholars not only from Australia but on every continent. The term transcultural nursing is sometimes used interchangeably with cross-cultural, intercultural, or multicultural nursing. Some have used the terms ethnic nursing care, cultural safety, or care for people of color as they have endeavoured to provide sensitive, meaningful, relevant, congruent, safe, and competent nursing and health care for individuals, families, groups, and communities from diverse backgrounds. It should be noted that Leininger is the only nursing leader who has developed, implemented, and evaluated a theory, the Theory of Culture Care Diversity and Universality, and a research method, ethnonursing, to facilitate the study of phenomena of interest in transcultural nursing. A qualitative research method, ethnonursing is the only research method developed by a nurse for nurses and others to use when studying about topics such as culture, care, caring, and related subjects. From its inception transcultural nursing was
Volume 28, Issue 1–2, April 2008
CN
13
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 14
Margaret M Andrews
conceptualised by Leininger (1966, 1969, 1970, 1978, 1995; Leininger & McFarland 2002, 2006) as global in nature.The concept of globalisation fits the broad scope and nature of transcultural nursing, and Australia has been a key leader in the global paradigm focus for more than two decades (Andrews 2006; Omeri 1998, 2003, 2004; Omeri & Cameron-Traub 1996; Percival 1995, 1996). Leininger (1995, 2007) has identified key historical periods or phases in the development of transcultural nursing. During the First Era (1955 to 1975): Establishing the Field of Transcultural Nursing, Leininger recognised the relationships between nursing and anthropology, but kept a focus on nursing and the benefits of having a theory. From 1975 to 1983, a period that Leininger has identified as the Second Era: Program and Research Expansion for Transcultural Nursing, growing numbers of nurses became interested in the valuable contribution of transcultural nursing around the world. The Third Era: Establishing Transcultural Nursing Worldwide (1983 to present) is the period during which transcultural nursing’s global agenda has been the primary focus. As Dr Leininger has recently reflected on the evolution of transcultural nursing, she has added a phase that she refers to as Breakthroughs in Transcultural Nursing to Make the Discipline a Reality, and she comments on some decisions and strategies to support transcultural nursing as a discipline (Leininger 2007). Establishing transcultural nursing world wide has required transcultural nurse leaders who are creative, innovative, and visionary. Australia is among the most multicultural nations in the world and many key transcultural nursing leaders are Australian (Omeri 1998, 2003, 2004, 2005; Omeri & Cameron-Traub 1996; Percival 1996; Royal College of Nursing, Australia 2000). Increasing numbers of nurses have been travelling and working in different countries, and interacting with people from many different cultures electronically and face-to-face. Nurses 14
CN
Volume 28, Issue 1–2, April 2008
and members of other health-related disciplines have been using transcultural nursing concepts, principles, and research in their practice, teaching, and scholarly investigations, and many have formally studied transcultural nursing and health care in degree and/or certificate programs. Australia has been a leader in the globalisation of transcultural nursing. In 1994, the Royal College of Nursing, Australia (RCNA) established a Transcultural Nursing Society, thus providing national leadership by creating a forum for nurses interested in culturally relevant nursing care practice, and it continues to be the only national nursing organisation in Australia to support transcultural nursing with a Transcultural National Network for its members. On an international level, RCNA is actively involved in encouraging international affiliation with other nursing groups and individual membership of nurses in the Asia–Pacific region. In addition to RCNA’s membership in the International Council of Nurses (ICN) and leadership in promoting ICN-related activities in the region, it also sponsored an international transcultural nursing conference in collaboration with transcultural nursing leaders from the US, New Zealand and elsewhere in the world, thus firmly establishing Australia as a Regional and International leader in transcultural nursing by attracting nurses worldwide. In 2000, the 26th Annual Transcultural Nursing Research Conference was held on the Gold Coast, an event that also marked the 40th anniversary of Dr Leininger’s first visit to Australia. During each of her 15 visits to Australia, Dr Leininger has noted that many immigrant and non-immigrant nurses in Australia have become leaders in transcultural nursing practice, education, and research both within the country and the larger Pacific region. Australian transcultural nurses have been influential leaders through their shared scholarship in a wide variety of professional publications, including Contemporary Nurse, which dedicated the entire October 2003 issue to Dr
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 15
Commentary: Global leadership in transcultural practice, education and research Leininger and advances in contemporary transcultural nursing. Australian nurses also have shared their expertise in transcultural nursing practice, education and research in the Journal of Transcultural Nursing. Established in 1988 by Dr Madeleine Leininger, the purpose of this publication is to share scholarly work among transcultural nurses and others with an interest to disseminate transcultural nursing knowledge. In recent years the focus of articles in this journal has increasingly reflected the transnational expansion of transcultural nursing. There also have been transnational comparative analyses that contribute to transcultural nursing’s development thus contributing significantly and substantively to the globalisation of TCN theory and research. The composition of the Editorial Board for the Journal of Transcultural Nursing includes representatives from Australia and other nations around the world.
CN
tice, education, research, administration, and consultations transnationally in the form of evidence-based, best practices in transcultural nursing. Opportunities for transcultural collaboration among nurses and health care professionals from other disciplines has steadily increased each year. Transcultural nursing has become global in its focus, interests, and practices, and Australian nurses have been – and continue to be – leaders in the globalisation of transcultural nursing.
REFERENCES
Andrews MM (2006) Globalization of transcultural nursing theory and research, in Leininger MM and McFarland MR (eds) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, pp 83–114. Jones Bartlett, Sudbury MA. Davidson PM, Meleis A, Daly J and Douglas M (2003) Globalisation as we enter the 21st century: Reflections and directions for nursing education, science, research, and CONCLUDING REMARKS clinical practice. Contemporary Nurse 15(3): There is currently an extensive body of TCN 162–174. knowledge generated by transcultural nurses Leininger MM (1966) Convergence and divergence around the world, many of whom have used of human behavior:An ethnopsychological Leininger’s Theory of Culture Care Diversity comparative study of two Gadsup villages in the and Universality and the ethnonursing research Eastern Highlands of New Guinea. Doctoral method to study culture care and caring dissertation,The University of Washington, transnationally. Australian transcultural nurses Seattle WA. have contributed significantly to the globalisa- Leininger MM (1969) Ethnoscience: A promistion of TCN theory and research, and many are ing research approach to improve nursing responsible for breakthroughs in research, edupractice. Image: The Journal of Nursing Scholarship 3: 22–28. cation, and practice that have significantly Leininger MM (1969) Ethnoscience: A new and advanced TCN knowledge about culture care promising research approach for the health and related topics of relevance and interest in sciences. Image: The Journal of Nursing Scholartranscultural nursing from a global perspective ship 3: 2–8. (Leininger 2005). Davidson et al (2003) define and discuss globalisation as a force for improv- Leininger MM (1970) Nursing and Anthropology: Two Worlds to Blend.Wiley, New York. ing health care for all and critically analyse the Leininger MM (1978) Transcultural Nursing: Conneed to go from cultural competency to social cepts,Theories, and Practices.Wiley, New York. advocacy, noting the long history of social advo- Leininger MM (1985) Qualitative Research Methods cacy by the nursing profession. in Nursing. Grune Stratton, Orlando FL. There is now rigorous, theoretically solid, Leininger MM (Ed) (1989) Editorial: Inaugural and research-based knowledge in transcultural Issue of Journal of Transcultural Nursing. Journal of Transcultural Nursing 1: 1–2. nursing that needs to be applied to clinical prac-
Volume 28, Issue 1–2, April 2008
CN
15
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 16
Margaret M Andrews
Leininger MM (1990) The significance of cultural concepts in nursing. Journal of Transcultural Nursing 2(1): 52–59. Leininger MM (1995) Transcultural Nursing: Concepts,Theories, Research & Practices. McGrawHill, New York. Leininger MM (1997) Overview of the theory of culture care with the ethnonursing research method. Journal of Transcultural Nursing 8: 32–52. Leininger MM (2001) Founder’s focus: Australia: The global Transcultural Nursing Society’s 26th Annual Meeting Place for 2000. Journal of Transcultural Nursing 12: 158. Leininger MM (2005) Founder’s address:Transcultural nursing: Meeting the challenges of global health care.Transcultural Nursing Society 31st Annual Conference, 19–22 October 2003, New York. Leininger MM (2007) The evolution of transcultural nursing with breakthroughs to discipline status. Accessed at www.madel eine-leininger.com on 10 February 2008. Leininger MM and McFarland MR (Eds) (2002) Transcultural Nursing: Concepts,Theories, Research & Practices, 3rd edn. McGraw-Hill, New York. Leininger MM and McFarland MR (Eds) (2006), Culture Care Diversity and Universality:AWorldwide Theory of Nursing, 2nd edn. Jones & Bartlett, Sudbury MA. Omeri A (1995) A bedside manner to transcend borders, University of Sydney News 27(9), 26 April.
Omeri A (1996) Transcultural nursing care values and beliefs of Iranian immigrants in NSW Australia. Unpublished doctoral thesis, The University of Sydney, Australia. Omeri A (1998) Course charts cultural shift. Nursing Review: 23. Omeri A (1998) Nursing lecturer wins top international award. The University of Sydney News 12 (November): 5. Omeri A (2003) Meeting diversity challenges: Pathway of ‘advanced’ transcultural nursing practice in Australia. Contemporary Nurse 15(3): 175–187. Omeri A (2004) Transcultural nursing:Where from here!, Australia. Connections 7: 35. Omeri A (2005) Omeri wins transcultural nursing scholar award. Nursing Review 2005. Omeri A and Cameron-Traub E (Eds) (1996) Transcultural Nursing in Multicultural Australia. Royal College of Nursing, Canberra, accessed at www.rcna.org.au on 21 May 2008. Percival E (1995) Australia Transcultural Nursing Society Bulletin 1. RCNA Resources, Canberra. Percival E (1996) Foreward, in Omeri A and Cameron-Traub E (Eds) Transcultural Nursing in Multicultural Australia. Royal College of Nursing, Canberra, accessed at www.rcna .org.au on 21 May 2008. Royal College of Nursing, Australia (2000) Position Statement: Nursing in a Culturally Diverse Australia, accessed at www.rcna.org.au on 8 February 2008.
N O W AVA I L A B L E O RPHANED
BY THE
C OLOUR
OF
M Y S KIN : A S TOLEN G ENERATION S TORY
by Mary Terszak; ISBN 978-1-921348-08-2; vi + 156 pages; 2007 Told from the heart, this book is a rare autobiographical ethnography on the impact of forced institutionalisation on an Aboriginal Australian. In the raw voice of a grandmother, the book journals the author’s maternal separation, her search for family, identity and community, broken marriage, psychological breakdown and emotional reconstruction. It provides an in-depth account of the experience of a ‘Stolen Generation’ Australian and the struggle of these vulnerable members of our society. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected]; www.e-contentmanagement.com
16
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 17
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 17–22.
CN
E X E M P L A R Developing a new Bachelor of Nursing course responsive to Australia’s culturally diverse community Key Words Australia; cultural competence; curriculum development; cultural safety; nurse education; transcultural nursing
CN
LYNETTE M RAYMOND
Received 11 July 2007 Accepted 26 March 2008
INTRODUCTION
T
he purpose of this article is to discuss issues surrounding the development of a new Bachelor of Nursing course for the University of Notre Dame, Sydney, Australia. In particular, the focus of the discussion is on the factors that influenced the development of learning outcomes that would enable student nurses the opportunity to develop the knowledge, skills, and attitudes needed to advance both personally and professionally a cultural awareness of self and others appropriate for the Australian context and delivery of culturally congruent and safe nursing care.
BACKGROUND Over the past several decades, I have worked as a lecturer in nursing at several New South Wales universities and colleges. During that time, I have observed a diversity of teaching and learning approaches utilised by staff to develop cultural self-awareness and cultural competence among undergraduate and postgraduate student nurses. I have also observed a growing trend towards implementing learning outcomes that
Clinical Coordinator/Senior Lecturer The University of Notre Dame Sydney NSW, Australia
focused only on one or a limited number of the evidenced-based cultural theoretical or conceptual approaches currently available to health professionals.1 This approach to teaching student nurses about the role culture plays in influencing the health and well-being of all individuals, I believe does not encourage students to become critical thinkers, nor does it demonstrate a sustained scholarship culture. Learning outcomes that limit the examination of the evidenced-based research and health care policies available to inform practice is not congruent with the goals of higher education in Australia, nor the role of universities to utilise research to advance knowledge and understanding (MCEETYA, 2007). Therefore, the aim of the new Bachelor of Nursing course was to develop a curriculum that reflected both stakeholders’ views and a diverse range of evidencedbased research on culture care and cultural safety relevant to nursing practice for the Australian context. The Bachelor of Nursing (BN) is a comprehensive three-year course, which prepares student nurses to meet the Australian Nursing and
Volume 28, Issue 1–2, April 2008
CN
17
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 18
Lynette M Raymond
Midwifery Council (ANMC) National Competency Standards for the Registered Nurse (2006) that are currently required for registration by the Nurses and Midwives Board in each state and territory of Australia. A transfer of state and territory registration to national registration in Australia is anticipated during 2008 to 2010.The new University of Notre Dame, Australia Bachelor of Nursing course (Sydney Campus) aims to provide the student with essential knowledge, skills, attitudes and experiential learning that will prepare the student for the role of a professional nurse in order to provide safe care across various clinical settings and socio-cultural contexts. Graduates will be able to practise at a beginning level in a variety of health agencies and settings, under the direction of or with access to, experienced registered nurses (RNs), until a level of independent practice is achieved. The BN course also extends attitudes and skills of the professional nurse, through researching contemporary health care/ nursing issues, exploring the impact of health policy and socio-cultural issues on health and the modes used in bringing about change in health care delivery.
CURRICULUM DEVELOPMENT PROCESS It became apparent early in the curriculum development process that in order to meet the diverse cultural health needs of the Australian community, a diverse range of professional stakeholders’ views needed to be sought.The curriculum developers needed to identify what culturally relevant content needed to be included in the course units of study and learning outcomes. The developers of the course also needed to know how the Bachelor of Nursing curricula could provide teaching and learning opportunities for the student nurse so that they could further develop their levels of cultural awareness, knowledge, skills, and attitudes that could lead to culturally safe and competent practice (NSWNMB 2005a, 2005b; ANMC 2006). 18
CN
Volume 28, Issue 1–2, April 2008
A wide range of professional and community representative opinions were obtained during the early stages of the curriculum development. Initially, the School of Nursing’s External Advisory Committee (EAC) was formed. The EAC comprised of representatives from the university sector, clinical experts from the health care service sector and consumers of professional nursing care. Representatives from a diverse range of clinical areas included: Rural and Remote Health Nursing, Aboriginal and Torres Strait Islander Health, Mental Health, Aged Care, Community and Primary Health Care Nursing and registered nurse members from other medical and surgical specialty areas currently working in hospitals. Other resources included clinicians and consultants with experience and expertise in the delivery of multicultural, transcultural, primary health, and representatives from community and culture-specific health care services (Wass 2000; O’Connor-Flemming Parker 2001). In addition to these resources, current evidenced-based research, Australia’s health strategic plans and policy requirements were identified and used as a guide (RCNA 1998; DEST 2002; Commonwealth of Australia 2006; NSW Department of Health 2007). Furthermore, the providers of Aboriginal and Torres Strait Islander health care services opinions were also investigated (Commonwealth of Australia 2004; Goold 2004; Eckerman et al 2005; S. Goold, personal communication, 13 December 2005 and 23 March 2006; Couzos & Murray 2008). The review of the literature revealed a diverse range of culture care theories and conceptual models of cultural safety and competence are currently available and in use by nurses and midwives globally (CampinhaBacote 2002; Leininger & McFarland 2002; Andrews & Boyle 2003; Purnell & Paulanka 2003; Giger & Davidhizar 2004; Spector 2004; Papps 2005; Wepa 2005;Jirwe Gerrish Emami 2006).The literature also indicated the culture care theories and conceptual models are utilised by researchers and clinicians in a diverse range
CNJ 28_1_2_internal.qxd
14/07/2008
12:23 PM
Page 19
Exemplar: Developing a new Bachelor of Nursing course of specialty nursing and midwifery domains both in Australia and overseas (Omeri 1996; Nahas & Amasheh 1999; Raphael & Malak 2001; Leininger & McFarland 2002; Andrews & Boyle 2003; Omeri, Lennings & Raymond 2005; Raymond 2003). Nevertheless, in some instances specific cultural groups were found to identify more readily with one particular theoretical cultural approach over and above others. For instance, the conceptual model of cultural safety originally developed in New Zealand by Ramsden (2005) for Maori nurses and the Maori population, has been adopted by Australia’s Aboriginal and Torres Strait Islander peoples (Goold 2004; Papps 2005 & Wepa 2005). The conceptual model of cultural safety together with primary health care model are utilised by Aboriginal Health Workers and nurses working with Indigenous communities, as a preferred method of achieving cultural self-awareness, sensitivity and culturally safe nursing and midwifery practice (O’Donoghue 1999; NSW Department of Health 2001, 2003, 2005;Thomson 2003; Commonwealth of Australia 2004; Eckerman et al 2005; Richardson & Carryer 2005; Kelly 2006; Couzos & Murray 2008). Conversely, the ‘transcultural nursing theory of culture care diversity and universality’ devised by Leininger (1978; 2002) was found to be both suitable and fitting for the Australian context (Liamputtong 1994; Omeri 1996; Nahas & Amasheh 1999; Kanitsaki 2003; Raymond 2003).The culture care theory enables the discovery of culture specific care knowledge, skills, and attitudes that can utilised by nurses and midwives to guide practice in a diverse range of clinical contexts. The culture care theory and accompanying ethnonursing research findings also enhances the growth of professional knowledge and understanding, thus contributing to scholarship and goals of higher education in Australia.The culture care theory was also found to be congruent with the principles underpinning Australia’s Multiculturalism Agenda, as well as the Australian Governments views and
CN
policies on cultural diversity, health promotion, and illness prevention (Omeri & Cameron-Traub 1996; Omeri 2002, 2003; Commonwealth of Australia 2003, 2006; NSW Department of Health 2007). The principles of Australia’s Multiculturalism Agenda emphasise the importance of valuing differences, access and equity, and utilising the cultural knowledge and skill contributions of people from different backgrounds, experiences and perspectives to generate new ideas and ways of doing things in all sectors of society (Commonwealth of Australia1999, 2003). Similarly, the health aims of federal, state and territory governments primarily focus their health and ageing health policies on the principles of primary health care, promotion of healthy lifestyles, early intervention and prevention of illness from within a social model of health framework (Germov 2004; Daly, Speedy, Jackson 2005; Grbich 2005; Gray 2006; Commonwealth of Australia 2007; McMurray 2007;NSW Department of Health 2007).
REFLECTIONS The findings from the EAC inquiry and review of the literature indicated that it would be therefore, both scholarly and culturally prudent to include and teach the diverse range of culture care theories and the conceptual model of cultural safety in the new Notre Dame Bachelor of Nursing course curriculum.To achieve this aim, it was decided that the general course objectives and specific unit learning outcomes relating to cultural diversity and culturally safe nursing practice needed to be embedded in all the course units, in addition to the development of two discrete units of study. The two specific non-elective units of study are titled Aboriginal and Torres Strait Islander Health Care and Transcultural Nursing, and are included in the final year of the course. Other supportive units of study designed to enhance a student’s growth towards cultural self-awareness and cultural competence include units of study such as: an introduction
Volume 28, Issue 1–2, April 2008
CN
19
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:23 PM
Page 20
Lynette M Raymond
to nursing in the Australian context; psychology; sociology; maternal and child health; family; aged and community primary health care; ethics and legal studies; professional role of the nurse; in addition to core nursing care units offered throughout the three years of the course. The decision to be inclusive rather than exclusive was based on the need for student nurses to be offered teaching and learning opportunities that encouraged critical thinking, scholarship and informed clinical decision-making that is specific to the social and cultural context in which the nurse or midwife practises. An education curriculum that encourages reflection and critical analyses of the diverse range of evidenced-based culture care theories is also more likely to enhance the student’s life long journey of acquiring cultural awareness (self and others), knowledge, skills, and attitudes required for the delivery of culturally congruent, safe, sensitive, and competent nursing care. During 2008, the University’s first cohort of student nurses will be undertaking their final year of study and the two specific non-elective units of study Aboriginal and Torres Strait Islander Health Care and Transcultural Nursing. The students undertaking these units will be taught and assessed for cultural self-awareness and cultural competence utilising a diverse range of cultural self-awareness assessment tools that were introduced in their first year units of study (Leininger & McFarland 2002; Purnell & Paulanka 2003; Giger & Davidhizar 2004; Wepa 2005; Munoz & Luckmann 2008). It is envisaged that, following completion of the BN course, the graduate nurses will be culturally safe and competent to enter the role of registered nurse – as the graduate nurse will be expected to have the necessary knowledge, skills, and attitudes needed for working safely in a culturally and linguistically diverse country such as Australia. It is planned that one year post graduation, the graduates will be invited to participate in a study that evaluates their views on the suitability and value of their course preparation for advancing 20
CN
Volume 28, Issue 1–2, April 2008
their personal and professional cultural selfawareness and cultural competency capability for working with culturally and linguistically diverse patients and other health care workers.
Endnote 1 A group of scholars from the Transcultural Nursing Society (Global) is currently in the process of compiling a resource book for those nurses seeking TCN certification.This resource, a collection of nine to ten chapters will include a comprehensive section on all the current theories and models available in transcultural nursing to date. This publication will be available late 2008 (Omeri 2008). References Andrews M and Boyle J (2003) Transcultural Concepts in Nursing Care, 4th edn, Lippincott Williams and Wilkins, Philadelphia, USA. ANMC (2006) National Competency Standards for the Registered Nurse, 4th edn, ANMC, Canberra, ACT. Retrieved 26 February 2006 from http://www.anmc.org.au/profes sional_standards/index.php. Campinha-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: A model of care, Journal of Transcultural Nursing 13: 181–184. Commonwealth of Australia (2006) Corporate Plan 2006–09: Better health, better care, better life, Department of Health and Ageing, Canberra, ACT. Retrieved 26 March 2007 from http://www.health.gov.au/internet/ wcms/publishing.nsf/content/corporateplan Commonwealth of Australia (2004) A National Strategic Framework for Aboriginal and Torres Strait Islander Mental Health and Social and EmotionalWell-being 2004–2009, Social Health Reference Group for National Aboriginal and Torres Strait Islander Health Council and National Mental Health Working Group, Canberra, ACT. Commonwealth of Australia (2003) Multicultural
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 21
Exemplar: Developing a new Bachelor of Nursing course Australia: United in diversity. Updating the 1999 new agenda for multicultural Australia: Strategic directions for 2003–2006, Canberra, ACT. Commonwealth of Australia (1999) Australian Multiculturalism for a New Century: Towards inclusiveness, National Multicultural Advisory Council, Canberra, ACT. Couzos S and Murray R (eds) (2008) Aboriginal Primary Health Care.An evidenced-based approach, 3rd edn, Oxford University Press, South Melbourne,Victoria. Daly J, Speedy S and Jackson D (eds) (2005) Contexts of Nursing, 2nd edn, MacLennan and Petty, Sydney. Department of Education Science and Training (2002) National Review of Nursing Education, Department of Education, Science and Training (DEST), Canberra, ACT. Retrieved April 24, 2003, from www.dest.au/highered nursing/pubs/multi-cultural Eckermann A, Dowd T, Martin M, Nixon L, Gray R and Chong E (2005) Binanj Goonj: Bridging cultures in Aboriginal health, 2nd edn, University of New England Press, Armidale, NSW. Germov J (ed) (2005) Second Opinion.An Introduction to Health Sociology, 3rd edn, Oxford University Press, Melbourne. Goold S (2004) The future is now – live it, ACORN 17: 9–11. Gray D (2006) Health Sociology:An Australian perspective, Pearson Prentice Hall, Australia. Grbich C (ed) (2005) Health in Australia: Sociological concepts and issues, 3rd edn, Pearson Longman, Sydney. Giger J N and Davidhizar R (2004) Transcultural Nursing Assessment and Intervention, 4th edn, Mosby, St Louis, Missouri. Jirwe M, Gerrish K and Enami A (2006) The theoretical framework of cultural competence, The Journal of Multicultural Nursing and Health 12: 6–16. Kanitsaki O (2003) Transcultural nursing and challenging the status quo, Contemporary Nurse 15(3): v–x.
CN
Kelly J (2006) Is it Aboriginal friendly? Searching for ways of working in research and practice that support Aboriginal women, Contemporary Nurse 22(2): 317–326. Liamputtong R (ed) (1994) Asian mother,Australian birth, pregnancy, childbirth and childrearing. The Asian experience in an English speaking country,Ausmed Publications, Melbourne. Leininger M (ed) (1978) Transcultural Nursing Concepts,Theories and Practices, Greyden Press, Columbus, Ohio. Leininger M and McFarland M (eds) (2002) Transcultural Nursing Concepts,Theories, Research and Practice, 3rd edn, McGraw-Hill, New York. Leininger M (2002) The theory of culture care and ethnonursing research method. In M Leininger and M McFarland (eds) (2002) Transcultural Nursing Concepts Theories, Research and Practice, 3rd edn, McGraw-Hill, New York. McMurray A (2007) Community Health and Wellness.A socioecological approach, 3rd edn, Elsevier, Australia. Ministerial Council on Education, Employment, Training and Youth Affairs (2007) National Protocols for Higher Education Approval Processes. MCEETYA, Canberra, ACT. Retrieved 28 March 2008 from http://www.mceetya .edu.au/mceetya/national-protocols-forhigher-education-mainpage,15212.html Munoz C and Luckmann J (2008) Transcultural Communication in Nursing, 2nd edn,Thomson Delmar Learning, Australia. Nahas V and Amasheh N (1999) Culture care meanings and experiences of postpartum depression among Jordian Australian women: A transcultural study, Journal of Transcultural Nursing 10: 37–45. NSW Department of Health (2007) Future Directions for Health in NSW – Towards 2025: Fit for the future, NSW Department of Health, North Sydney, NSW. Retrieved 26 March 2007 from http://www.health.nsw.gov.au /pubs/2007/pdf/future_directions.pdf.
Volume 28, Issue 1–2, April 2008
CN
21
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 22
Lynette M Raymond
NSW Department of Health (2005) NSW Aboriginal Maternal and Infant Health Strategy Evaluation Final Report 2005, NSW Department of Health, North Sydney, NSW. NSW Department of Health (2003) NSW Health Aboriginal Health Impact Statement and Guidelines, NSW Department of Health, North Sydney, NSW. NSW Health Department and the Aboriginal Health and Medical Research Council of NSW (2001) NSW Aboriginal Health Promotion Program: Directions paper. Gladesville, NSW: Better Health Centre Publications Warehouse. Nurses and Midwives Board of New South Wales (2005a) NMB Update 2: 14–18. Nurses and Midwives Board of New South Wales (2005b) Retrieved 7/28/2005 http:// www.nmb.nsw.gov.au/ne_inspections.htm O’Donoghue L (1999) Towards a culture of improving Indigenous health in Australia, Australian Journal of Rural Health 7: 64–69. O’Connor-Flemming M and Parker E (2001) Health Promotion: Principles and Practice in the Australian Context, Allen and Unwin, NSW. Omeri A, Lennings C and Raymond L (2005) Beyond asylum: Implications for nursing and health care delivery for Afghan refugees in Australia, Journal of Transcultural Nursing 17: 1–31. Omeri A (2003) Meeting diversity challenges: Pathway of ‘advanced’ transcultural nursing practice in Australia, Contemporary Nurse 15(3): 175–187. Omeri A (2002) Reflections on Australia and transcultural nursing in the new millennium, in Leininger M and McFarland M (eds) (2002) Transcultural Nursing Concepts,Theories, Research and Practice, 3rd edn, McGraw-Hill, New York. Omeri A and Cameron-Traub E (eds) (1996) Transcultural Nursing Care in Multicultural Australia, Royal College of Nursing, Australia, ACT. Omeri A (1996) Transcultural nursing care values, beliefs and practices of Iranian 22
CN
Volume 28, Issue 1–2, April 2008
immigrants in New South Wales Australia. PhD (Nursing), Faculty of Nursing,The University of Sydney, Australia. Papps E (2005) Cultural safety: daring to be different, In Wepa D (ed) Cultural safety in Aotearoa New Zealand, Pearson Education, New Zealand. Purnell L and Paulanka B (2003) Transcultural Health Care.A culturally competent approach, 2nd edn, F.A. Davis Company, Philadelphia, USA. Raphael B and Malak A (eds) (2001) Diversity and Mental Health in Challenging Times, Transcultural Mental Health Centre, Parramatta, NSW. Ramsden I (2005) Towards cultural safety, in Wepa D (ed) Cultural Safety in Aotearoa, New Zealand, Pearson Education, New Zealand. Raymond L (2003) An ethnonursing study of the culture care meanings of health and wellbeing for Mauritian immigrant childbearing families living in New South Wales Australia. Unpublished doctoral thesis. Faculty of Nursing, Department of Family and Community Nursing,The University of Sydney. Richardson F and Carryer J (2005) Teaching Cultural Safety in a New Zealand Nursing Education Program, Journal of Nursing Education 44: 201–208. Royal College of Nursing, Australia (1998) Position Statement: Nursing practice in a culturally diverse Australian society. Council of Royal College of Nursing, Australia, Canberra, ACT. Spector R (2000) Cultural Diversity in Health and Illness, 5th edn, Prentice Hall Health, Uppersaddle River, NJ. Thomson N (ed) (2003) The Health of Indigenous Australians, Oxford University Press. South Melbourne,Victoria. Wass A (2000) Promoting Health.The primary health care approach, 2nd edn, Harcourt Saunders, Sydney. Wepa D (2005) Cultural Safety in Aotearoa, New Zealand, Pearson Education, New Zealand.
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 23
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 23–36.
Use of the culture care theory and ethnonursing method to discover how nursing faculty teach culture care ABSTRACT
Key Words culture care theory; ethnonursing research method; teaching culture care; research; nursing education; culturally congruent care
As the world becomes increasingly multicultural, transcultural nursing education is critical to ensuring a culturally competent workforce.This paper presents a comprehensive review of literature and results of an ethnonursing pilot study using the Culture Care Theory (CCT) to discover how nursing faculty teach culture care. The literature revealed that despite 50 years of transcultural nursing knowledge development through theory, research and practice, there remains a lack of formal, integrated culture education in nursing.The importance of faculty providing generic and professional care to nursing students and using an organising framework to teach culture care was discovered. Additionally, care was essential for faculty health and well-being to enable faculty to teach culture care.This unique use of the theory and method demonstrates its usefulness in discovering and describing the complex nature of teaching culture care. Larger scale studies are predicted to further substantiate the CCT, building the discipline of nursing. Received 16 July 2007
SANDRA J MIXER Assistant Professor of Nursing Middle Tennessee State University Murfreesboro TN
A
s the world becomes increasingly multicultural, transcultural nursing education, practice, research and administration are imperative to respond to the global health needs of people, communities and nations.Within the profession
Accepted 26 February 2008
CN
of nursing, there is a need and dictum to increase cultural sensitivity and competence in nursing students (AACN 2004; McFarland & Leininger 2002; Sullivan 2004; US Department of Health and Human Services 1996). Nursing educators worldwide are challenged to prepare a culturally competent nursing workforce (McFarland & Leininger 2002). The culture of the nursing profession embraces the shared value of preparing students to provide culturally competent nursing care for people in an increasingly multicultural world (AACN 2004; US Department of Health and Human Services 1996;Wilson et al 2003). The increasing diversity in the population in the
Volume 28, Issue 1–2, April 2008
CN
23
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 24
Sandra J Mixer
United States and in countries throughout the world compels nurses to examine cultural characteristics of persons and caring practices of nurses (Hegyvary 2006). According to estimates by the US Census Bureau (2005), 33% of the American population in 2005 was made up of persons from ethnic, non-white backgrounds as represented by: 14.4% Hispanic/Latino, 12.8% African American, 4.3% Asian, 1% American Indian/Alaskan Native and 0.2% Native Hawaiian/Pacific Islander. Nursing faculty have the responsibility to effectively disseminate transcultural nursing knowledge to ensure a culturally competent workforce prepared to deliver satisfying, safe and beneficial nursing care. As this researcher contemplated nursing students learning to provide culturally congruent care, curiosity about faculty culture care competence and knowledge, skills and values necessary to effectively teach culture care emerged. Therefore, a pilot study was developed to discover nursing faculty care expressions, patterns and practices related to teaching culture care. This article presents the review of literature and pilot study findings. A comprehensive review of literature was informative and essential for developing the domain of inquiry and research questions. Discoveries from this pilot study are useful for nursing faculty as they prepare students to provide culturally congruent care in a multicultural world.
LITERATURE REVIEW Introduction Culture care education in nursing focuses broadly on nurses, nursing students and faculty developing transcultural expertise; the ability to provide culturally congruent care for people from similar and diverse cultures (Leininger 2006a). Developing this expertise is multifaceted and is described in the literature as involving cultural awareness and sensitivity, cultural competence, cultural skills, cultural content, teaching strategies, culturally diverse clinical 24
CN
Volume 28, Issue 1–2, April 2008
sites, cultural immersion experiences and institutional cultures. Focus has been placed on what is taught, how it is taught and personal and professional reflection of the nursing professional. Following is a critical discussion of the literature including research studies that address culture care education in nursing.
Cultural competence development Cultural competence development has been described as a process or journey rather than a destination. One does not become culturally competent; rather one works toward cultural competence throughout one’s professional nursing career (Campinha-Bacote 2005). The Cultural Self-Efficacy Scale (CSES) was developed by Bernal and Froman to address a nurse’s knowledge about ‘cultural concepts, cultural patterns and skills in performing transcultural nursing functions’ (Coffman et al 2004: 181). Early studies using the CSES were conducted to measure the cultural competence of senior nursing students. Alpers and Zoucha (1996) found that introducing cultural concepts and care of diverse people into a course was insufficient in raising students’ perception of cultural competence; and Kulwicki and Boloink (1996) found that students had little or no confidence in caring for people representing African Americans, Latino-Hispanics, Middle Easterners/Arabics, Asian/Pacific Islanders and Native American minority groups. Researchers suggested comprehensive transcultural nursing education needs to be incorporated into curricula. Strategies included teaching lifeways of various cultures, cultural assessment, facilitating students in exploring their values and beliefs related to cultural differences and similarities (Alpers & Zoucha 1996), purposefully selecting clinical sites that allow students to care for diverse people and clinical faculty role modeling (Kulwicki & Boloink 1996). Interestingly, when Coffman, Shellman and Bernal (2004) reviewed 26 known uses of the CSES ‘findings showed that ethnicity, previous coursework and
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 25
How nursing faculty teach culture care educational experiences can increase nurses’ self-efficacy in delivering culturally competent care’ (Coffman et al 2004: 185). After conducting an exhaustive review of literature, Rew et al (2003) proposed that cultural competence can be conceptualised as consisting of cultural awareness, cultural sensitivity, cultural knowledge and cultural skills. These authors developed and tested a cultural awareness scale (CAS) which was found to be a reliable and valid instrument for measuring cultural awareness in nursing students. Additionally, researchers concluded that data ‘support the multidimensional nature of cultural awareness’ and the importance of faculty modeling sensitivity to cultural diversity (Rew et al 2003: 225). Jeffreys and Smodlaka (1999) found transcultural self-efficacy to be higher for senior versus beginning nursing students. Both groups were most confident about their transcultural attitudinal self-evaluations and were least confident in their transcultural nursing knowledge. Students participating in the study represented diversity in terms of age, gender, ethnicity, income, previous health care experience and language. Results substantiated that simply belonging to a minority group does make one culturally competent.The researchers concluded that formal, transcultural nursing education, including cultural immersion experiences, are required to prepare nurses to provide culturally congruent care (Jeffreys & Smodlaka 1999). In determining the effectiveness of a curriculum to teach students cultural competence, Sargent et al (2005) found that fourth year nursing students were more culturally competent than first year students. Researchers concluded that cultural competence can be effectively taught when purposefully integrated throughout the curriculum using active teaching strategies. Examples of these strategies are completing a cultural self-assessment, comparing and contrasting one’s culture to a person from a different culture through interview and review of
CN
literature and caring for people from diverse backgrounds.The authors suggested that cultural desire [described by Campina-Bacote (2003) as motivation to become culturally competent] of students and faculty alike may be the most significant factor in developing cultural competence (Sargent et al 2005).
Teaching strategies A descriptive survey was conducted by Ryan, Carlton and Ali (2000) to ascertain trends in teaching transcultural nursing concepts and learning experiences in baccalaureate and master’s programs in the United States. Faculty from 217 National League for Nursing accredited programs responded, equating to a 36% response rate. Researchers found great diversity among schools about what was taught related to culture and transcultural nursing (TCN) and how these concepts were taught. TCN content was found in most nursing curricula; however substantive content and integration throughout the curriculum were missing. Although formal programs of transcultural nursing study at the masters’ and doctoral level are available at several universities, the survey found insufficient numbers of faculty with expertise in TCN available to teach and some schools reported no qualified faculty were available. Researchers suggested that more substantive content related to transcultural nursing be integrated throughout curricula rather than simply offering modules or an elective course. Additionally, Ryan et al (2000) recommended greater support for faculty development in transcultural nursing at the department and university levels to foster faculty expertise. Majumdar et al (2004) administered six instruments to health care providers and patients randomly divided into experimental and control groups over one and one half years to determine the effectiveness of cultural sensitivity training on health care providers’ knowledge and attitudes and how this training affected patient care satisfaction in home care and hosVolume 28, Issue 1–2, April 2008
CN
25
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 26
Sandra J Mixer
pital settings. Providers in the experimental group received 36 hours of cultural sensitivity training at the beginning of the study with baseline instrument assessment and then had instruments administered to them and their patients at three, six and 12 months. Health care providers in the control group received training just before the last data collection phase. The study began with 114 health care providers and 133 patient volunteers. At each phase of the study, patients dropped out due to illness or death and providers due to relocation resulting in approximately 75 providers and 47 patients completing all phases of the study. Despite the study being conducted in an urban setting where one quarter of the population was foreign born, demographics of the health care providers and patients were similar with participants being from predominately European descent and the Roman Catholic and Protestant faiths (Majumdar et al 2004). The findings showed that health care providers who had received the cultural sensitivity training earlier conducted more thorough cultural assessments and rated culture as more important than those in the control group. Once providers in the control group received training, they responded similarly. Qualitative and quantitative data revealed providers who had received training demonstrated improved communication with minority patients as well as more open-mindedness and insight toward caring for people different than themselves.The health care expenditures among long term community patients were reduced by $7,000 over 1.5 years of the study. Researchers concluded that cultural sensitivity training improves culture care (Majumdar et al 2004). Baldonado et al (1998) surveyed 767 registered nurses and baccalaureate nursing (BSN) students from the east coast, west coast and midwest of the US using the Transcultural and International Nursing Knowledge Inventory (TINKI).This questionnaire included closed and open-ended questions related to participants’ 26
CN
Volume 28, Issue 1–2, April 2008
experiences in providing culture care.The registered nurses and BSN students reported little confidence in caring for culturally diverse people and they learned about how to care for diverse people most often from experience in caring for them. Few participants had received any formal transcultural nursing education from their professional preparation, continuing education, or reading; and thus, did not describe care actions and decisions based on a conceptual framework. Researchers assessed that these participants were at the first stage of transcultural nursing knowledge as described by Leininger – cultural awareness. Themes identified in the research reflected that nurses and students overwhelmingly perceived a need for transcultural nursing and they modified care to meet their client’s culture care needs. Recommendations were that transcultural nursing concepts and clinical experiences in caring for people from diverse cultures be integrated in all levels of curricula (associate degree through doctoral level) and in continuing education programs for practicing nurses (Baldonado et al 1998). Canales and Bower (2001) conducted a grounded theory research study of ten doctoral prepared, Latino nurse educators. It was discovered that these educators viewed culture and culturally competent practice very broadly. They teach students how to care for anyone who is ‘different’ from them using strategies of connecting directly through communities and immersion in the lives of those they care for. Researchers suggested the need to expand how cultural competence is conceptualised in nursing research, education and practice to caring for anyone who is different from oneself (Canales & Bower 2001). At St. Luke’s College in Kansas City, Missouri transcultural nursing principles were purposefully integrated throughout the nursing curriculum. Students were taught to examine their own cultural backgrounds, values and beliefs. They were taught transcultural nursing
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 27
How nursing faculty teach culture care theory, Leininger’s Culture Care Theory, the ethnonursing research method and cultural assessment using the Giger-Davidhizar Transcultural Assessment Model. Students learned about racial and ethnic groups in the local community and the US and biological variations in laboratory and clinical settings. Groups conducted in-depth studies of cultural groups and used posters to present their learning to one another, at professional meetings, in the school of nursing and in staff lounges in hospitals (Hughes & Hood 2007). The Cross-Cultural Evaluation Tool developed by Freeman (as cited in Hughes & Hood 2007) is a five-point Likert-type scale which was used to measure student ability to make culturally sensitive choices. The tool was used with students as a pretest-posttest instrument. Hughes and Hood (2007) found that nursing students became more culturally sensitive after engaging in these specific strategies to teach transcultural nursing. A variety of additional teaching strategies were identified in the literature as effective for teaching culture care. A sampling of the strategies discovered is shared here. Brennan and Schulze (2004) assigned students to analyse one of seven randomly chosen ethnographies using teacher-set criteria that addressed cultural factors. Students then gathered in groups to discuss, share and seek clarification of meanings in the ethnographies.This teaching/learning activity resulted in students examining their ethnocentrism and broadened their understanding of cultural diversity.The need to engage students’ affective and cognitive domains of learning through experiential learning was identified by Carpio and Majumdar (1993) as necessary for effective culture care education. In addition, they purported that the teacher was responsible to create a learning environment where cultural diversity was viewed positively rather than negatively or as a threat. Finally, Evans and Severtsen (2001) taught novice nursing students to use story telling for cultural assessment.
CN
Through practice with peers and then clients in a long-term care clinical setting, students learned to ‘listen in a nonjudgmental, contextual way to the values and beliefs of the storyteller’ (Evans & Severtsen 2001: 180).
Cultural immersion In a study using a triangulated research design, St. Clair and McKenry (1999) explored the relationship between short term international nursing clinical immersion experiences, cultural self-efficacy and cultural competence.Two hundred senior and graduate nursing students participated over a two year time frame. Eighty students chose international immersion experiences while the remaining 120 students cared for culturally diverse populations in the United States.While both groups of students exhibited a statistically significant increase in cultural selfefficacy as measured by the CSES, students who participated in a two to three week international clinical immersion reported a greater increase than those who remained in the US. Analysis of qualitative data further revealed that the international immersion experience facilitated students in recognizing their ethnocentrism and need to develop cultural sensitivity and awareness (St Clair & McKenry 1999). Integrating cultural content in an undergraduate nursing program was found to produce small to moderate gains in students’ perceived cultural competence. However, for students participating in a five-week international cultural immersion experience, perceived cultural competence gains were large. Authors discussed the importance of students’ values and attitudes in motivating their commitment to provide culturally competent care. Opportunities to care for persons very different from oneself were found to be critical in developing confidence and practice expertise (Caffery et al 2005). Hern et al (2005) discussed a strategy to develop cultural sensitivity, a global community perspective and cultural competence through collaboration. Exchanges were arranged among Volume 28, Issue 1–2, April 2008
CN
27
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 28
Sandra J Mixer
practicing nurses in the US and Scotland and among faculty in the US and in Korea. Student nurses and faculty traveled to Honduras for a two week cultural immersion experience in the community. Faculty concluded at least two weeks or more was required to travel and assimilate to a new culture and nursing environment.They pointed out, ‘a week long exchange is not sufficient to gain sensitivity to the other culture’ (Hern et al 2005: 41). The authors developed a workplace model for practice and education partnering which included: beginning with a shared vision; developing infrastructure; securing funding; identifying outcomes for practice, education and research; marketing these programs; and focusing on future collaboration. The importance of institutional support was stressed. Authors identified more similarities than differences existed among cultural groups involved (Hern et al 2005). A collaborative partnership between the University of Pittsburgh and Miami Children’s Hospital was created for senior nursing students’ final, practice-intensive semester. The purpose was to cultivate undergraduate nursing students’ cultural competence through exposure to people from different cultures. Clinical nurse specialists in Miami coordinated the clinical experience of students with preceptors there and with faculty in Pittsburgh. Extensive communication among all participants facilitated the process. Technology such as video conference calls, e-mail and a course web-page were used. Students received scholarships to fund the experience. Authors shared examples of student learning gained from caring for patients and families from Jamaican, Hispanic and Haitian backgrounds (Hoffman et al 2005). Ryan, Twibell, Brigham and Bennett (2000) conducted a qualitative study of nine practicing registered nurses who had participated in a cultural immersion experience while earning their baccalaureate degrees in nursing. Graduates stressed that while classroom activities and 28
CN
Volume 28, Issue 1–2, April 2008
content were important, their immersion experience was critical to facilitating ‘learning to care’. Participants provided vivid examples of how these immersion experiences influenced them to provide culturally competent care. Rather than offering an elective course, suggestions were made for transcultural care to be viewed as ‘essential’ and integrated throughout the curriculum (Ryan et al 2000). Additionally, Ryan and Twibell (2002) found that personal growth, increased sensitivity to the needs of others and a general expansion of one’s worldview were outcomes of participating in a cultural immersion experience. Based on this review of literature, clinical cultural immersion experiences are transformative resulting in nursing students’ growth in providing culturally competent nursing care, addressing the holistic perspective of ethnocentrism and cultivating cultural sensitivity and awareness. Some researchers wondered whether national immersion experiences might be equally as effective as international experiences in challenging students’ ethnocentrism and growth in cultural competence (St. Clair & McKenry 1999). In our world of international instability and students with limited financial resources, national immersion experiences may be an appropriate option for students and warrants further study.
Institutional culture Teaching culture care requires institutional support and a cultural climate where people and experiences which are different and similar are valued and embraced. Yearwood et al (2002) held one focus group with seven student volunteers representing diverse races, religions, nationalities and genders to explore diversity. Topics included what diversity is, the role of the school of nursing and university and ideas about incorporating diversity in courses and clinical experiences. Data gathered has application to nursing education and teaching culture care. Students defined diversity as ‘differences bet-
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 29
How nursing faculty teach culture care ween people including biological, religious, sexual orientation, life and family style’ and that diversity was ‘mostly about color’ (Yearwood et al 2002: 238). Students were confused by the university focus on embracing diversity while encouraging cultural events and ethnic organisations that focused on differences that separated groups of students. Students offered the following suggestions for faculty interested in facilitating development of cultural sensitivity: small group activities to encourage the opportunity to work with people different from oneself; promoting discussion and tolerance; focus on experiential learning versus lecture; and a course on cultural diversity incorporated into the curriculum (Yearwood et al 2002). From the educational literature, Marchesani and Adams (1992) tackled the increasing diversity in the student population in higher education in America and proposed a four-part model for teaching and learning in a multicultural context. Dimensions were directly related to facilitating a teaching/learning environment which values diversity and fosters exploration and achievement of cultural competence. Components of the model speak to knowing oneself, knowing one’s students, developing coursework where diverse perspectives are presented and teaching with a variety of strategies to promote success in students from varied backgrounds. Schmitz et al (1992) provided an in-depth description of implementing the ‘Classroom Climate Project’ in their university.The purpose was to develop classrooms with an effective multicultural context for learning.The goal was for faculty to create a warm and inviting, inclusive environment where students were valued and respected. The framework used for faculty development was Palmer’s model for learning and behavioral change which involves four stages necessary to create lasting change in the classroom; discovering, formulating new behaviors, producing new behaviors and generalisation to the real world. Authors identified the critical ingredient for creating this environment
CN
is ‘a teacher who appropriately recognises and values different cultural styles and perspectives and effectively engages students in the learning process’ (Schmit et al 1992: 75). In addition, the authors pointed out efforts for multicultural learning must involve system wide changes. Similarly, Grossman et al (1998) illuminated incongruence between stated philosophical values related to multicultural learning and actual practice. In a survey of Deans and Directors of nursing programs in Florida, programs shared their mission and philosophy statements and conceptual frameworks which supported cultural diversity and reported that cultural content was either integrated throughout the curriculum or taught in a specific transcultural nursing course.Yet, lack of cultural knowledge, sensitivity and awareness was most frequently identified by participants as a critical issue related to cultural diversity in their nursing programs (Grossman et al 1998). Institutional commitment to cultural diversity and creating a climate for teaching culture care should be demonstrated in the institution’s mission statement, by financial resources for faculty, staff and student development and through faculty and students valuing diversity and multiculturalism (Schmitz et al 1992). Creating multicultural learning environments in the university setting is dependent on a ‘large-scale, complex, sustained organisational and cultural transformation’ (Marchesani & Adams 1992: 10).
Review of literature conclusion Teaching culture care in nursing education is critical to ensuring a culturally competent workforce. The literature indicates faculty are not adequately prepared to teach culture care or mentor students in cultural sensitivity.The literature suggests culture care and cultural competence are complex phenomena requiring broad, holistic approaches and teaching strategies to promote student understanding and application in their nursing practice.There is ambiguity and lack of consensus in the literature about the Volume 28, Issue 1–2, April 2008
CN
29
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 30
Sandra J Mixer
meaning and use of the terms ‘cultural competence’ and ‘culturally congruent care’. This researcher referred to these terms as they were used by authors in their articles. Overwhelmingly, researchers recommend that formal transcultural nursing be integrated throughout the curriculum (Alpers & Zoucha 1996; Baldonado et al 1998; Hughes & Hood 2007; Ryan, Carlton & Ali 2000; Ryan, Twibell et al 2000; Sargent et al 2005) and that cultural immersion experiences are essential for learning to provide culturally congruent care (Bosworth et al 2006; Caffery et al 2005; Ryan,Twibell et al 2000; Ryan & Twibell 2002; St Clair & McKenry 1999). While nursing programs and institutions of higher learning may have mission and philosophy statements supporting diversity and cultural content incorporated in curricula, the literature reflects there is incongruence between what is stated and the practices of faculty and students in classroom and clinical settings (Canales & Bowers 2001; Cook & Cullen 2000; Evans 2004; Gardner 2005; Grossman et al 1998). Learning to embrace the diverse and similar needs of nursing students and the individuals, families and communities cared for requires a deep level of personal, faculty, college and university commitment (Campinha-Bacote 2005; Cook & Cullen 2000; Edwards 2003; Newman & Williams 2003). Cultural diversity must be valued and respected by institutional culture and integrated throughout nursing curricula to move beyond cultural awareness and cultural sensitivity to cultural competence. There are gaps in the quantitative and qualitative research literature about the preparation faculty have had in transcultural nursing and in teaching about culture care, cultural diversity and culturally congruent and competent care. Few studies were found which used nursing theory as a framework for nursing research and practice related to teaching culture care. Many studies have been conducted using a variety of quantitative measurement tools to measure student learning about culture and related con30
CN
Volume 28, Issue 1–2, April 2008
cepts. In conclusion, there have been no studies conducted to discover nursing faculty care expressions, patterns and practices related to teaching culture care nor have there been any ethnonursing research studies conducted using the Culture Care Theory in this context. Results of the following pilot study provide preliminary research in preparation for a major study to fill this gap.
PILOT STUDY: PURPOSE, GOAL AND DOMAIN OF INQUIRY The domain of inquiry for this transcultural nursing pilot study was nursing faculty teaching culture care within the environmental context of an urban baccalaureate nursing program in a public university in the southeastern United States.This domain of inquiry is a major interest in nursing because of the growing diversity of the population in the United States, concerns about the provision of global health care and the call for more nurses prepared in transcultural nursing. The researcher predicted that nursing faculty epistemology (knowing how to teach culture care) and ontology (faculty modeling culturally congruent care) are essential to teach students to provide culturally congruent care. The purpose of this study was to discover, describe and systematically analyse the care expressions, patterns and practices of nursing faculty related to teaching culture care.The goal of this study was to discover faculty care that facilitates teaching baccalaureate nursing students learning how to provide culture care. Research questions In studying the domain of faculty teaching culture care within the environmental context of undergraduate baccalaureate programs in nursing, two broad questions were used within the ethnonursing research method to guide the researcher.These research questions were: 1. In what ways do nursing faculty care expressions, patterns and practices influence teaching culture care?
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 31
How nursing faculty teach culture care
CN
sions and major concepts of the theory) (Leininger 2006a) provided the framework for this research study (Figure 1).This nursing theory was chosen because of the researcher’s interest in using the theory in the context of nursing education and its relevance to the Theoretical framework The Culture Care Theory (CCT) together with domain of inquiry. The Culture Care Theory the Sunrise Enabler (which depicts an inte- provides a holistic means to understand the grated holistic view of the influencing dimen- range of factors that influence nursing faculty 2. In what ways do worldview, culture and social structure and environmental context influence nursing faculty teaching culture care?
FIGURE 1: LEININGER’S SUNRISE ENABLER
TO
DISCOVER CULTURE CARE
Source: Copyright M Leininger 2004. Reprinted with permission from Dr Leininger.
Volume 28, Issue 1–2, April 2008
CN
31
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 32
Sandra J Mixer
teaching culture care. McFarland & Leininger (2002) proposed that nursing education in the 21st century must become ‘transculturally grounded’ (McFarland & Leininger 2002: 528) by considering the phenomena of student, faculty and client culture care values, beliefs and practices. Previously, there have been no studies conducted to discover these phenomena related to teaching culture care and no ethnonursing research studies conducted using the Culture Care Theory in this context.
Ethnonursing research method Leininger developed the ethnonursing research method to study transcultural human care phenomena using her theory of Culture Care Diversity and Universality (Leininger 2006a). The method uses an open, largely inductive process of discovery to document, describe, understand and interpret peoples’ care meanings and experiences (Leininger 2006b) and therefore is useful to understand the realities of faculty teaching culture care.The ethnonursing method embraces the importance of discovery from the people’s (emic) ways of knowing and gives credence to the professional nurse’s (etic) way of knowing (Leininger 2006b). Key informants are those people holding the most knowledge about the domain of inquiry while general informants provide reflective data about teaching culture care, stimulating the researcher to focus on care similarities and differences among informants. Nursing faculty as knowers were purposefully selected for participation in this research study. Key informants were full time tenure-track nursing faculty while general informants were full time, non-tenure track and adjunct faculty. Three key informants (who held doctoral degrees) and three general informants (advanced practice nurses) participated in this pilot study. All informants were female, ranging in age from 27 to 55 years old and had between 1.5 and 27 years of teaching experience. Four were African American, two were Anglo-Ameri32
CN
Volume 28, Issue 1–2, April 2008
can (German/English-American [n = 1] and English/French American [n = 1]who further identified herself as a ‘liberal southerner’) and two spoke some Spanish. None of the informants had ever had a course in transcultural nursing. Four participants continued to participate in direct client care and three had psychiatric nursing backgrounds. Approval was received from the University of Northern Colorado Institutional Review Board and written consent was obtained from all participants. Data was gathered using unstructured, open-ended interviews, participant observation and extensive field notes. Data were analyzed using Leininger’s four phases of ethnonursing analysis for qualitative data and application of the qualitative criteria of credibility, confirmability, meaning-in-context, recurrent patterning and saturation (Leininger 2006b).
PILOT STUDY FINDINGS Based on data analysis, three major themes were discovered by the researcher. The first theme was Faculty provided generic and professional care to nursing students to maintain and promote healthy and beneficial lifeways within the environmental context of a baccalaureate nursing program. Faculty expressed they learned to care from their families, friends and mentors, ‘I learned how to care by people caring for me.’ Caring was learned and taught to students through mentoring and role modeling; ‘listening’, ‘being approachable’, ‘checking in’. Care was reciprocal and multidimensional. The second theme discovered was Faculty taught students culture care with major differences among classroom, on-line and clinical contexts but without an organising conceptual framework. Some faculty taught culture care in classroom and online contexts, generally within a course module or reading assignment. All faculty explicitly taught culture care during clinical experiences which occurred in community and acute care contexts. Faculty spoke about the diversity of the client population in the urban setting, ‘just
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 33
How nursing faculty teach culture care
CN
by the nature of being in our clinic they had to address all those cultural issues.’ Faculty described their nursing students had many opportunities to care for Asian, Hispanic, African American and African patients and families. Most faculty taught culture care without an organising conceptual framework. Culture care was taught at the cultural diversity level as faculty only discussed cultural competence related to race/ethnicity rather than from a broader perspective. The third theme discovered was care is essential for faculty health and well-being and to enable faculty to teach culture care to baccalaureate nursing students. Faculty expressed the importance of mutuality as caring and mentoring. Mentoring occurred related to teaching coursework, scholarly work and how to ‘be’ as a faculty member. Mentors impressed the importance of caring for oneself to be enabled to care about others and balancing the tripartite faculty roles of teaching, scholarship and service. Caring was expressed as providing leadership to create a healthy caring community for faculty. Some faculty took responsibility for their part in creating this community ‘I think everybody has to take their responsibility for the school; it’s not just one person, but it’s a collective effort’; while others felt administrators were responsible. Diversity within this theme was discovered. Non-care was expressed as not assisting new faculty, faculty not being on time for meetings and overt and covert racism. ‘There is still the great divide (in the city)… the great racial divide.’ Another informant expressed that within the school of nursing the ‘racial environment is charged from both sides.’ A third informant discussed difficulty in trusting colleagues; therefore, she sought mentoring and encouraging relationships within a minority professional nursing organisation.
of research discoveries in nursing care using the three modes of culture care actions and decisions. These modes are derived from synthesis and analysis of qualitative study data and then confirmed with informants for accurate meanings. Culture Care Preservation/Maintenance refers to those assistive, supporting, facilitative, or enabling professional actions and decisions that help nursing faculty retain and preserve relevant care expressions, patterns and practices to teach culture care and contribute to the health of faculty, students and clients (derived from Leininger 2006a: 8). Discoveries from this study suggest nursing faculty should maintain efforts to assist students to care for culturally diverse clients in the clinical setting. For example, nursing faculty discussed working hard to ensure each nursing student had the opportunity to care for patients and families from different ethnic cultural groups. Faculty expressed the importance of being mentored in learning how to care and in turn provided extensive mentoring and role modeling for students as they learned to provide care. Culture Care Accommodation/Negotiation refers to those assistive, supporting, facilitative, or enabling professional actions and decisions that help nursing faculty adapt to or negotiate with others relevant care expressions, patterns and practices to teach culture care and contribute to the health of faculty, students and clients (derived from Leininger 2006a: 8). Findings from this study suggest nursing faculty may wish to negotiate integrating culture care content into established nursing courses throughout the curriculum and introduce required and elective courses on culture care. While all informants valued teaching culture care, there was limited formal transcultural nursing concepts taught. No formal courses existed to teach culture care and there was no integration of culture care content across the curriculum. Culture Care Repatterning/Restructuring refers Discoveries for teaching to those assistive, supporting, facilitative, or culture care The Culture Care Theory includes application enabling professional actions and decisions that
Volume 28, Issue 1–2, April 2008
CN
33
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 34
Sandra J Mixer
help nursing faculty reorder, change, or greatly modify relevant care expressions, patterns and practices to teach culture care and contribute to the health of faculty, students and clients (derived from Leininger 2006a: 8). An important finding from this study was culture care repatterning/restructuring may be used with nursing faculty to establish the culture care theory as an organising framework for teaching culture care in the classroom, on-line and clinical contexts. The use of a theoretical basis for teaching culture care is necessary to assist faculty and students in moving beyond a view of culture as race/ethnicity to a broader, holistic view. Such an expanded worldview facilitates students and faculty respecting and understanding patients’ and families’ cultural values, beliefs and lifeways resulting in beneficial and satisfying care (derived from Leininger 2006a: 4).
CONCLUSION Despite 50 years of transcultural nursing knowledge development through theory, research and practice, there remains a lack of formal, integrated culture education in nursing (Baldonado 1998; Hughes & Hood 2007).This review of literature and pilot study offer nursing educators insight into factors influencing teaching culture care in nursing programs. Findings are useful for nurse educators in university settings as they seek to prepare nursing students to provide meaningful, satisfying and beneficial care for people who are similar to and different from them resulting in nurses prepared to provide culturally congruent care in a multicultural world. Culturally diverse and similar students may be recruited and thrive in nursing programs where teaching culture care is embraced (McFarland et al 2006; Pacquiao 2007). The Culture Care Theory with the Sunrise Enabler and ethnonursing research method provided a useful framework and method for this pilot study. This unique use of the theory and method demonstrates its usefulness in dis34
CN
Volume 28, Issue 1–2, April 2008
covering and describing the complex nature of teaching culture care within the environmental context of university schools of nursing. Conducting a larger scale research study is predicted to further support and substantiate the Culture Care Theory; thus contributing to building knowledge for the discipline of nursing and specifically the practice of nursing in the areas of nursing education and the provision of culturally congruent and competent care.
Acknowledgements Funding for this research was received from Middle Tennessee State University, Faculty Research and Creative Projects Committee and Xi Alpha Chapter of Sigma Theta Tau, International Honor Society of Nursing. The author wishes to acknowledge expertise and support from the University of Northern Colorado faculty and my dissertation committee members: Dr Debra Leners, Dr Marilyn McFarland, Dr Margaret Andrews and Dr Linda Lohr. References Alpers RR and Zoucha R (1996) Comparison of cultural competence and cultural confidence of senior nursing students in a private southern university, Journal of Cultural Diversity 3: 9–15. American Association of Colleges of Nursing (2004) Online FY05-06 Strategic Plan. Accessed at http:www.aacn.nche./edu/ContactUs /Strtplan.htm on 1 October 2004. Baldonado A, Ludwig Beymer P, Barnes K, Starsiak D, Nemivant EB and Anonas-Ternate A (1998) Transcultural nursing practice described by registered nurses and baccalaureate nursing students, Journal of Transcultural Nursing 9: 15–25. Bosworth TL, Halburdo EP, Hetrick C, Patchett K,Thompson MA and Welch M (2006) International partnerships to promote quality care: Faculty groundwork, student projects and outcomes, The Journal of Continuing Education in Nursing 37: 32–38.
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 35
How nursing faculty teach culture care Brennan SJ and Schulze MW (2004) Cultural immersion through ethnography:The lived experience and group process, Journal of Nursing Education 43: 285–288. Caffrey RA, Neander W, Markle D and Stewart B (2005) Improving the cultural competence of nursing students: Results of integrating cultural content in the curriculum and an international immersion experience, Journal of Nursing Education 44: 234–240. Campinha-Bacote J (2005) A Biblically Based Model of Cultural Competence in the Delivery of Healthcare Services,Transcultural CARE Associates, Cincinnati, OH. Campinha-Bacote J (2003) The Process of Cultural Competence in the Delivery of Healthcare Services: A culturally competent model of care,Transcultural CARE Associates, Cincinnati, OH. Canales MK and Bowers BJ (2001) Expanding conceptualizations of culturally competent care, Journal of Advanced Nursing 36: 102–111. Carpio BA and Majumdar B (1993) Experiential learning: An approach to transcultural education for nursing, Journal of Transcultural Nursing 4: 4–11. Coffman MJ, Shellman J and Bernal H (2004) An integrative review of American nurses’ perceived cultural self-efficacy, Journal of Nursing Scholarship 36: 180–185. Cook PR and Cullen JA (2000) Diversity as a value in undergraduate nursing education [Electronic version], Nursing and Health Care Perspectives 21: 178. Edwards K (2003) Increasing cultural competence and decreasing disparities in health [Electronic version], Journal of Cultural Diversity 10(4): 111–12. Evans BC (2004) Application of the caring curriculum to education of Hispanic/Latino and American Indian nursing students, Journal of Nursing Education 43: 219–228. Evans BC and Severtsen BM (2001) Storytelling as cultural assessment, Nursing and Health Care Perspectives 22: 180–183. Gardner J (2005) Barriers influencing the
CN
success of racial and ethnic minority students in nursing programs, Journal of Transcultural Nursing 16: 155–162. Grossman D, Massey P, Blais K, Geiger E, Lowe J, Pereira O, Stewart A,Taylor R, Filer V, Nembhard J and Tally-Ross N (1998) Cultural diversity in Florida nursing programs: A survey of deans and directors, Journal of Nursing Education 37: 22–26. Hegyvary ST (2006) Health disparities related to race and ethnicity, Journal of Nursing Scholarship,Third Quarter: 205. Hern MJ,Vaugh G, Mason D and Wietkamp T (2005) Creating an international nursing practice and education workplace, Journal of Pediatric Nursing 20: 34–44. Hoffman RL, Messmer PR, Hill-Rodriguez DL and Vazquez D (2005) A collaborative approach to expand clinical experiences and cultural awareness among undergraduate nursing students, Journal of Professional Nursing 21: 240–243. Hughes KH and Hood LJ (2007) Teaching methods and an outcome tool for measuring cultural sensitivity in undergraduate nursing students, Journal of Transcultural Nursing 18: 57–62. Jefferies MR and Smodlaka I (1999) Construct validation of the transcultural self-efficacy tool [Electronic version], Journal of Nursing Education 38: 222–227. Kulwicki A and Boloink BJ (1996) Assessment of level of comfort in providing multicultural nursing car by baccalaureate nursing students, Journal of Cultural Diversity 3: 40–45. Leininger M (2006a) Culture care diversity and universality theory and evolution of the ethnonursing method, in Leininger M and McFarland MR (eds) Culture Care Diversity & Universality:A worldwide nursing theory, 2nd edn, Ch 1, Jones & Bartlett, New York. Leininger M (2006b) Ethnonursing research method and enablers [Revised reprint] in Leininger M and McFarland MR (Eds) Culture Care Diversity & Universality:A worldwide nursing
Volume 28, Issue 1–2, April 2008
CN
35
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 36
Sandra J Mixer
theory, 2nd edn, Ch 2, Jones & Bartlett, New York. Majumdar B, Browne G, Roberts J and Carpio B (2004) Effects of cultural sensitivity training on health care provider attitudes and patient outcomes, Journal of Nursing Scholarship 36: 161–166. Marchesani LS and Adams M (1992) Dynamics of diversity in the teaching-learning process: A faculty development model for analysis and action, New Directions in Teaching and Learning 52: 9–20. McFarland MR and Leininger M (2002) Transcultural nursing: Curricular concepts, principles and teaching and learning activities for the 21st century, in Leininger M and McFarland MR (Eds) Culture Care Diversity & Universality:A worldwide nursing theory, 2nd edn, Ch 34, McGraw-Hill, USA. McFarland MM, Mixer SJ, Lewis AE and Easley CE (2006) Use of the Culture Care Theory as a framework for the recruitment, engagement and retention of culturally diverse students in a traditionally European American baccalaureate nursing program, in Leininger M and McFarland MR (Eds) Culture Care Diversity & Universality:A worldwide nursing theory, 2nd edn, Ch 8, Jones & Bartlett, New York. Newman M and Williams J (2003) Educating nurses in Rhode Island: A lot of diversity in a little place [Electronic version], Journal of Cultural Diversity 10: 91–95. Pacquiao D (2007) The relationship between cultural competence education and increasing diversity in nursing schools and practice settings, Journal of Transcultural Nursing 18: 28S–37S. Rew L, Becker H, Cookston J, Khosropur S and Martinez S (2003) Measuring cultural awareness in nursing students, Journal of Nursing Education 42: 249–257. Ryan M, Carlton K and Ali N (2000) Transcultural nursing concepts and experiences in nursing curricula, Journal of Transcultural Nursing 11: 300–307. Ryan M and Twibell RS (2002) Outcomes of a 36
CN
Volume 28, Issue 1–2, April 2008
transcultural nursing immersion experience: Confirmation of a dimensional matrix, Journal of Transcultural Nursing 13: 30–39. Ryan M,Twibell R, Brigham C and Bennett P (2000) Learning to care for clients in their world, not mine [Electronic version], Journal of Nursing Education 39: 402–408. Sargent SE, Sedlack CA and Martsolf DS (2005) Cultural competence among nursing students and faculty, Nurse Education Today 25: 214–221. Schmitz B, Paul S P and Greenberg J D (1992) Creating multicultural classrooms: An experience-derived faculty development program, New Directions for Teaching and Learning 42: 75–87. St Clair A and McKenry L (1999) Preparing culturally competent practitioners [electronic version], Journal of Nursing Education 38: 228–234. The Sullivan Commission: Kellogg Foundation (2004) Missing persons: Minorities in the health professions. A report of the Sullivan Commission on diversity in the healthcare workforce, Battle Creek MI, accessed at http://admissions.duhs.duke.edu/sullivanco mmission/index.cfm on 14 November 2006. US Census Bureau (2005) USA Quick Facts from the US Census Bureau, accessed at http://quick facts.census.gov/qfd/states/00000.html on 9 April 2007. US Department of Health and Human Services (1996) National Advisory Council on Nurse Education and Practice: Report to the Secretary of Health and Human Services on the Basic Registered Nurse Work Force, US Government Printing Office,Washington DC. Wilson AH, Sanner SJ and McAlliter LE (November 2003) The Honor Society of Nursing, Sigma Theta Tau International Diversity Resource Paper, accessed at http://www/ nursingsociety.org/about/Diversitypaper.pdf.on 9 April 2007. Yearwood EL, Brown DL and Karlik EC (2002) Cultural diversity: Student’s perspectives, Journal of Transcultural Nursing 13: 237–240.
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 37
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 37–44.
Cultural competency of graduating US Bachelor of Science nursing students ABSTRACT
Key Words nursing; cultural competency; BSN students; curriculum; nursing students
Cultural competence in the delivery of nursing care is an expectation of accreditation and approval boards for nursing in the United States.This study evaluated the effectiveness of four different nursing program curricula in developing culturally competent new graduates. Four methodologically and geographically diverse groups of graduating BSN students in the United States were given the Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-Revised (IAPCCC-R®) prior to graduation and after completion of course work.A variety of curricular methods for achieving cultural competency were included. Two programs utilise a theory or a model developed by recognised transcultural expert nurses, Madeline Leininger and Josepha Campinha-Bacote. One program utilised an integrated approach employing no specific model. One program utilised a free-standing two credit culture course within the curriculum, taught by nursing faculty with strong cultural preparation. Results indicate that these 212 graduating nursing students scored only in the culturally aware range, as measured by the IAPCC-R©, regardless of what program model they attended. Received 29 January 2008
M
Accepted 22 March 2008
CN
SUZAN KARDONG-EDGREN
JOSEPHA CAMPINHA-BACOTE
Assistant Professor Intercollegiate College of Nursing Washington State University Spokane WA, USA
President Transcultural CARE Associates Case Western Reserve University Cincinnati OH, USA
ost US schools of nursing include some reference to a culturally competent graduate in their program mission and/or outcome statement. Cultural competence in the delivery of nursing care is an expectation of accredita-
tion and approval boards for nursing (American Association of Colleges of Nursing [AACN] 1997; American Nurses Association 1986; NLN 2003). However to date, no studies are found in the literature evaluating which curricula are the
Volume 28, Issue 1–2, April 2008
CN
37
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 38
Suzan Kardong-Edgren and Josepha Campinha-Bacote
most successful in developing culturally competent graduates (Bond 2004; Grant & Letzring 2003; Jones & Bond 2000).This study evaluated the effectiveness of four different nursing program curricula in developing culturally competent new graduates. A universally agreed-upon definition of what cultural competency is, is still lacking although definitions are more alike than dissimilar. ‘Specific content is not defined in detail and there is a dearth of evidence based education studies on what to teach in a culturally competent curriculum’ (Bond 2004: 2). Multiple curricular strategies are employed by nursing programs to teach cultural competence and may include free-standing cultural courses, immersion and international experiences of varying lengths. Two outstanding curricula guides for teaching cultural competency, sponsored by the United State Department of Health and Human Services (USDHHS), recently became available to all online – USDHHS Office of Minority Health’s Culturally Competent Nursing Modules (CCNM) and USDHSS Health Resources and Services Administration’s document, Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education: The Role of the HRSA Centers of Excellence (Campinha-Bacote 2006). Integration across the curriculum is the most frequently cited method for teaching cultural material (Grant & Letzring 2003; Grossman et al 1998; Kardong-Edgren et al 2005; Lipson & DeSantis 2007). The integration model may allow programs to skirt the problems associated with the addition of cultural content, seen by many as soft science in a biomedically laden curriculum (Betancourt 2007). In addition, use of the integrated approach may mean cultural content is ‘implemented ad hoc by a committed few’ (Boyle 2007: 21S).The ability of faculty to integrate culture into a curriculum remains a question, although a recent study suggests faculty are increasingly culturally competent (Kardong-Edgren 2007). Some argue that the basic 38
CN
Volume 28, Issue 1–2, April 2008
definition of nursing as the diagnosis and treatment of human response to illness should preclude the need for teaching cultural competency as a topic at all (Dreher & McNaughton 2002). However, this approach discounts ‘the macrolevel sociological and economic factors in which this (health) encounter occurs and health decisions are made’ (Lipson & DeSantis 2007: 19S). While the debate continues about the best way to teach cultural content, ‘without adequate evaluation, we cannot know which is the most effective method to develop cultural competency’ (Lipson & DeSantis: 18S). There are no articles in the literature specifically evaluating cultural competency of graduating nursing students. The purpose of this study was to evaluate the cultural competency of graduating nursing students from programs using different kinds of curricular approaches. If one approach proved more efficacious, it might serve as a model for other programs struggling with best practices for teaching cultural content in their programs. This descriptive study used a post-test only design to measure the cultural competency of graduating BSN students from four geographically diverse nursing programs. Cultural competency is defined as ‘the process in which the healthcare provider continuously strives to achieve the ability to work effectively within the cultural context of a client, individual, family or community’ (Campinha-Bacote 2003: 54) for the purposes of this study. Five model constructs include: cultural desire, cultural awareness, cultural skill, cultural knowledge, and cultural encounters. Campinha-Bacote argues that the key to cultural competency is cultural desire, wanting to, rather than having to, learn and interact with other cultures.
LITERATURE REVIEW Many studies reported in the USA have evaluated the cultural competency of nursing students, using a variety of instruments (Bond, Kardong-
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 39
Cultural competency of graduating US Bachelor of Science nursing students Edgren & Jones 2001; Felder 1990; Pope et al 1994; Napholz 1999; Schlosser et al 2004; Zorn, Ponick & Peck 1995). Results have been mixed. Senior nursing students experienced increased self confidence with international study abroad experiences (St. Clair & McKenry 1999; Zorn et al 1995) and when receiving cultural content in a senior level community health class (Alpers & Zoucha 1996). However, other graduating senior students expressed little selfconfidence in their ability to care for ethnically diverse patients (Kulwicki & Bolonik 1996). The most frequently-cited method for teaching culture is integration across the curriculum (Grant & Letzring 2003; Kardong-Edgren et al 2005). This methodology might be considered suspect considering the oft-cited lack of faculty prepared to teach cultural material (Bond 2004; Leininger & McFarland 2002; Ryan et al 2000). The use of integration may have been a useful strategy to meet accreditation requirements, allowing those faculty who knew something about culture to address it and allowing those faculty who did not, to catch up. KardongEdgren (2007) found that nursing faculty were culturally competent, although this is contrary to recent findings (Kardong-Edgren et al 2005; Ryan et al 2000). Evaluating cultural competency in students is difficult because of a lack of appropriate instrumentation for this group. Most cultural competency tools have been normed on practicing nurses; students may lack ‘the experience needed to be aware of what they do not know’ (Coffman, Shellman & Bernal 2004: 184). Coffman et al recently advised against using the Cultural Self Efficacy Scale (CSES) with students. The CSES is the most frequently used tool for measuring cultural competency.
METHODOLOGY Campinha-Bacote’s (2003) Process of Cultural Competence in the Delivery of Healthcare Services model provided the conceptual framework for this study. The model constructs
CN
were measured using a version of CampinhaBacote’s Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-Revised (IAPCC-R©).The IAPCCR© is designed to measure the level of cultural competence among healthcare professionals and consists of 25 items that measure the five cultural constructs of desire, awareness, knowledge, skill and encounters. Five items address each construct.The IAPCC-R© uses a four-point Likert scale reflecting the response categories of strongly agree, agree, disagree, strongly disagree; very aware, aware, somewhat aware, not aware; very knowledgeable, knowledgeable, somewhat knowledgeable, not knowledgeable; very comfortable, comfortable, somewhat comfortable, not comfortable; and very involved, involved, somewhat involved, not involved. Completion time is approximately 10–15 minutes. Scores range from 25–100 and indicate whether a healthcare professional is operating at a level of cultural proficiency, cultural competence, cultural awareness or cultural incompetence. Higher scores depict a higher level of cultural competence. The IAPCC-R© has been used extensively with an average reliability coefficient Cronbach’s alpha of 0.83. Descriptive statistics about the sample population were collected including age, gender, previous experience in a foreign country and ability to speak a foreign language. This study compared scored on the IAPCC© R of graduating students from four schools of nursing. Schools were chosen in a snowball sample and after email conversations with representatives at each school. A variety of curricular methods for achieving cultural competency were included. Two programs utilise a theory or a model developed by recognised transcultural expert nurses, Madeline Leininger and Josepha Campinha-Bacote. One program utilised an integrated approach employing no specific model. One program utilised a free-standing two credit culture course within the curriculum, taught by nursing faculty with strong cultural preparation.
Volume 28, Issue 1–2, April 2008
CN
39
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 40
Suzan Kardong-Edgren and Josepha Campinha-Bacote
TABLE 1: PARTICIPANT
SCHOOLS , METHOD OF TEACHING CULTURE , AND PERCENTAGE RETURN
School
Potential participants Actual participants
Large eastern integrated curriculum (Campinha-Bacote) Large western free standing cultural course Small western integrated (Leininger) Large southwestern curriculum integrated Total
65 100 36 92 293
Graduating seniors in the fall semester of 2006 in all participating schools of nursing were asked to participate in the study. Each site coordinator gained institutional review board (IRB) approval from their respective school. Study surveys were given out at each institution, in November or December, before fall graduation, depending on the program and after all program content had been completed. Table 1 shows return rates by program. Seventy-five per cent of students eligible for the study chose to participate. Each student survey was coded with a number corresponding to the school name. As participating students handed in their surveys, they were invited to sign their name on a slip of paper that was put in a bag for a drawing for a USD 50 incentive prize, after all surveys were collected. Site coordinators mailed all study forms to a central location for statistical analysis. Data was analyzed using ANOVA.
RESULTS Competency scores for 218 students from four programs, as measured by the IAPCC-R©, were computed and reported as aggregate data by school. All program means were scored in the culturally aware range, as measured by the TABLE 2: PROGRAM
CN
58 83 86 72 75
IAPCC-R©. No curricular strategy appeared to be better than another.Tables 1 and 2 show the participant numbers, program response rates, program mean scores and descriptive statistics. The Cronbach’s alpha for the total sample was computed at 0.82. Post-test means of students from the four different programs were compared using a one-way ANOVA. Statistics by program are reported in Table 2. No significant difference between programs was found (F, 3214 = 1.24, P > 0.05). Extensive demographic data including ethnicity, gender, age, international student status, experience abroad, and prior educational degrees are reported.
DISCUSSION Results indicate that graduating nursing students scored only in the culturally aware range, as measured by the IAPCC-R©, regardless of what program model they attended. One might tend to think that the free-standing course would foster better results as students are concentrating efforts and thought for a specific period of time on culture, yet there was no difference. Programs with the most diverse student bodies, most international students, oldest and youngest student bodies, also did not fare better than any other program.
MEAN SCORES
Large eastern integrated (Campinha-Bacote) Large western free standing cultural course Small western integrated (Leininger) Large southwestern integrated
40
38 83 31 66 218
Percentage return
N
Mean
Std deviation
Cronbach’s alpha
38 83 31 66
73.95 70.46 70.97 70.70
8.298 11.238 12.758 6.187
0.87 0.81 0.85 0.79
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 41
Cultural competency of graduating US Bachelor of Science nursing students TABLE 3: STUDENT
CN
ETHNICITY, GENDER , AGE , INTERNATIONAL STATUS BY PROGRAM
Large eastern integrated Campinha-Bacote
Small western integrated Leininger
Large southwestern integrated
Large western freestanding
Total
Ethnicity/school
n
%
n
%
n
%
n
%
n
Asian Black Native American/ Alaskan Pacific Islander White Other Black and white Hispanic Hispanic/white Mex. American Italian American Spanish, Italian, French, Irish Total
5 2
13.2 5.3
1 0
3.2 0
14 9
21.2 13.6
4 2
4.8 2.4
24 13
0 1 29 1 0 1 0 0 0
0 2.6 76.3 2.6 0 2.6
0 1 28 1 1 0 0 0 0
0 3.2 90.3 3.2 3.2 0
1 1 32 8 0 7 0 1 0
1.5 1.5 48.5 12.1
0 3 72 3 0 1 0 0 1
0 3.6 86.7 3.6
1 6 161 13 1 8 1 1 1
1 83
1.2
9 74 83
10.8 89.2
0 38
0 31
10.6 1.5
0 66
1.2
1.2
% 11 6 0.5 2.8 73.9 6.0 .5 3.7 .5 .5 .5
1 .5 218 100
Gender Male Female Total
4 34 38
10.5 89.5
3 28 31
9.7 90.3
4 60 64
6.1 90.9
20 196 216
9.2 89.9 99.1
Age Mean Median Min Max
26.03 25 21 42
32.16 29 23 52
26.37 24 21 53
24.54 23 20 52
26.44 24 20 53
International status Yes Bangladesh Burma Hong Kong Iran Japan Nepal Nigeria Japan South Korea Ukraine Total
0
0
0
0
8 1 1 1 1 1 1 1
8
4
12
5.5
12
5.5
1.5 1.5 1.5 1.5 1.5 1.5 1.5
12.5
2 1 1 4
2.4 1.2 1.2 4.8
Volume 28, Issue 1–2, April 2008
CN
41
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 42
Suzan Kardong-Edgren and Josepha Campinha-Bacote
TABLE 4: STUDENT
VACATIONS OR MISSION TRIPS OUTSIDE THE
Large eastern integrated Campinha-Bacote Vacation/mission Yes/vacation Yes/mission
TABLE 5: PRIOR
n 38 9
% 100 23.7
Anthropology Prior degree Undergraduate Graduate Doctoral
CN
Large western freestanding
Total
n
%
n
%
n
%
n
%
29 4
93.5 12.9
43 5
65.2 7.6
69 19
83.1 22.9
179 37
82.5 17
Small western integrated Leininger
Large southwestern integrated
Large western freestanding
Total
n
%
n
%
n
%
n
%
n
%
22 0 34 4 0
57.9 0 89.5 10.5 0
14 5 29 4 0
45.2 16.1 93.5 12.9 0
3 16 10 2 1
4.5 24.2 15.2 3 105
26 16 7 2 0
31.3 19.3 8.4 2.4 0
65 37 80 12 1
29.8 17.0 36.7 5.5 1.5
One hundred percent of these students also had traveled outside the US on vacation (Table 4). Students from the program with the highest mean score had taken a previous anthropology course (Table 5).They also reported the largest percentage of students who had been on foreign mission trips, demonstrating the opportunity for cultural encounters, a key element in the development of cultural competency (Campinha-Bacote 2003). Some questions exist as to whether it is appropriate to evaluate cultural competence later in working life rather than at the end of a program (Lipson & DeSantis 2007). Yet, we evaluate student competencies of many other skills we value and expect graduates to perform at some minimum level of competency prior to graduation. The fact that there are very few tools to evaluate cultural competency, something that is becoming increasingly important as the demographics of the US changes, may be indicative of what we as nurses truly value. The particular tool, the IAPCC-R© chosen for this study, may be problematic. A paper and 42
Large southwestern integrated
EDUCATIONAL EXPERIENCE
Large eastern integrated Campinha-Bacote Type
Small western integrated Leininger
UNITED STATES
Volume 28, Issue 1–2, April 2008
pencil self-report tool is probably not the best method for evaluating such a value laden multidimensional concept like cultural competency. The IAPCC-R© is frequently used because of its length, ease of use, and reliability and validity. However, with a self-report tool, students are not actually challenged to demonstrate cultural competency in any meaningful way. In addition,Vito, Roszkowski and Wieland (2005) noted in a study of 695 student nurses that the IAPCC-R© could be further revised resulting in a higher reliability of this tool with student nurses. Currently a student version (IAPCCSV©) of the IAPCC-R© is being tested (Campinha-Bacote 2007). Technology will soon allow us to evaluate cultural competency in a more meaningful way. Some program are currently evaluating cultural competency with filmed standardised patient encounters, while others are writing cultural material into human patient simulation scenarios. Standardised patients from different cultural backgrounds in addition to objective structured clinical examinations (OSCEs), both long used
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 43
Cultural competency of graduating US Bachelor of Science nursing students
CN
in medicine, are becoming more common in ‘How do we effectively teach cultural competence in nursing education?’ nursing programs as evaluation tools. Voltaire states, ‘Judge others by their questions; rather than by their answers.’ The quesCONCLUSION The findings of this study raise more questions tions that studies such as this study raise will than answers. In an attempt to study the effec- provide nurse educators with focused research tiveness of four different nursing program cur- questions to explore as they continue the jourricula in developing culturally competent new ney towards cultural competence in nursing graduates, we found that there was no statis- education. tically significant difference of the level of culWe shall not cease from explorations; tural competence (all received a level of cultural and the end of all our exploring; awareness) of the students regardless of the type will be to arrive where we started; of cultural content and educational strategies and know the place for the first time. employed at their respective school.This raises —TS Eliot, Four Quartets the following questions. ‘Is cultural awareness a more realistic goal for graduating nursing students?’ Cultural competence is a process and it Acknowledgement may be more appropriate for faculty to expect a This study was funded by a grant from the US level of cultural competence to occur after National League for Nursing. graduation. Another question that can be raised is ‘What are the qualifications of faculty cur- References rently teaching cultural competence?’The Tran- Alpers RR and Zoucha R (1996) Comparison of cultural competence and cultural confidence of scultural Nursing Society offers international senior nursing students in a private southern certification in transcultural nursing; however, university. Journal of Cultural Diversity 3: 9–15. fewer than 75 nurses are currently certified in American Association of Colleges of Nursing transcultural nursing (Campinha-Bacote 2006). (1997) A Vision of Baccalaureate and Graduate Currently, there is one nurse in Australia certiNursing Education:The Next Decade (Position fied by the Transcultural Nursing Society. The Paper).Washington DC: Author. findings of this study do not reflect the qualita- American Nurses Association, Council on tive aspect of teaching cultural content, thus Cultural Diversity in Nursing Practice (1986) one cannot attest to the quality of the teaching. Cultural diversity in the nursing education Perhaps an even more fundamental question is curriculum:A guide for implementation. American ‘How committed are accrediting bodies to actuNurses Association. ally considering the question of cultural compe- Betancourt J (2007) Commentary on ‘Current approaches to integrating elements of cultural tency?’ How have the members of accrediting competence in nursing education’. Journal of boards been prepared in cultural competency? Transcultural Nursing 18: 25S–27S. And lastly, ‘Is a self-report evaluation tool the Bond ML (2004) Testimony to the Sullivan best way to assess cultural competence?’ Commission: Diversity in the HealthcareWorkforce. The American Nurses Association issued its Washington DC. first position statement on cultural diversity in Bond ML, Kardong-Edgren S and Jones ME nursing curricula in 1986 and since then, there (2001) Assessment of professional nursing has been ongoing discussion as to what is the students knowledge and attitudes about theoretical underpinning of cultural training patients of diverse cultures. Journal of within nurse education should be. Over 20 Professional Nursing 17: 305–312. years later, nurse educators continue to ask, Boyle J (2007) Commentary on ‘Current
Volume 28, Issue 1–2, April 2008
CN
43
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 44
Suzan Kardong-Edgren and Josepha Campinha-Bacote
approaches to integrating elements of cultural competence in nursing education’. Journal of Transcultural Nursing 21: 20S–22S. Campinha-Bacote J (2003) The Process of Cultural Competency in the Delivery of Healthcare Services: A Culturally Competent Model of Care. OH: Transcultural C.A.R.E. Associates. Campinha-Bacote J (2006) Cultural competence in nursing curricula: How are we doing 20 years later? Journal of Nursing Education 45: 243–244. Campinha-Bacote J (2007) Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals – StudentVersion.Transcultural C.A.R.E. Associates. Accessed 21 May 2007 from http://www.transculturalcare.net/ iapcc-sv.htm. Coffman M, Shellman J and Bernal H (2004) An integrative review of American nurses’ perceived cultural self-efficacy. Journal of Nursing Scholarship 36: 180–185. Felder EJ (1990) Baccalaureate and associate degree student nurse’s cultural knowledge of and attitudes toward Black American clients. Journal of Nursing Education 29: 276–282. Dreher M and McNaughton N (2002) Cultural competency in nursing: Foundation or fallacy? Nursing Outlook 50: 182–186. Grant LF and Lentzring TD (2003) Status of cultural competence in nursing education: A literature review. The Journal of Multicultural Nursing and Health 9: 6–13. Grossman D, Massey P, Blais K, Geiger E, Lowe J, Pereira O, Stewart A,Taylor R, Filer V and Nembhard J (1998) Cultural diversity in Florida nursing programs:A survey of deans and directors. Journal of Nursing Education 37: 22–26. Jones ME and Bond ML (2000) Personal adjustment, language acquisition and culture learning in short-term cultural immersion. International Review 2: 33–47. Kardong-Edgren S, Bond ML, Schlosser S, Cason C, Jones ME,Warr R and Strunk P (2005) Cultural attitudes, knowledge and skills of nursing faculty toward patients of four diverse cultures. Journal of Professional Nursing 21: 175–182. Kardong-Edgren S (2007) Cultural competency of nursing faculty. Journal of Nursing Education 46, 360–366. 44
CN
Volume 28, Issue 1–2, April 2008
Kulwicki A and Bolonik BJ (1996) Assessment level of comfort in providing multicultural nursing care by baccalaureate nursing students. Journal of Cultural Diversity 3: 40–45. Leininger M and McFarland M (2002) Transcultural Nursing: Concepts,Theories, Research and Practice, 3rd edn. San Francisco: McGraw-Hill. Lipson J and DeSantis L (2007) Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing 18: 10S–20S. National League for Nursing (2003) Innovation in Nursing Education:A Call to Reform. National League for Nursing New York. Napholz L (1999) A comparison of self-reported cultural competency skills among two groups of nursing students: Implications for nursing education. Journal of Nursing Education 38: 81–83. Pope-Davis D, Eliason M and Ottavi T (1994) Are nursing students multiculturally competent? An exploratory investigation. Journal of Nursing Education 33: 31–33. Ryan M, Carlton K and Ali N (2000) Transcultural nursing concepts and experiences in nursing curricula. Journal of Transcultural Nursing 11: 300–307. Schlosser S, Bourrand J,Warr S and Lowe M (2004) The Lived Academic Experience of African-American School of Nursing Graduates While Enrolled in a Private Religious-affiliated Majority University, 29th Annual Transcultural Nursing Society Conference, San Antonio. St. Clair A and McKenry L (1999) Preparing culturally competent practitioners. Journal of Nursing Education 38: 228–234. Vito K, Roszkowski M and Wieland D (2005) Measuring cultural competence as a curriculum outcome:What we learned from our experiences with two instruments, National League for Nursing Education Summit, Baltimore. Zorn C, Ponick D and Peck S (1995) An analysis of the impact of participation in an international study program on the cognitive development of senior baccalaureate nursing students. Journal of Nursing Education 34: 67–70.
CNJ 28_1_2_internal.qxd
14/07/2008
CN
12:24 PM
Page 45
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 45–47.
EDITORIAL Transcultural nursing theory and models: The challenges of application IRENA PAPADOPOULOS Professor Transcultural Health and Nursing, and Head Research Centre for Transcultural Studies in Health Middlesex University London UK
T
he European Union has declared 2008 the European Year of Intercultural Dialogue. This is in recognition that Europe is becoming more culturally diverse. Globalisation has increased the multicultural character of many countries, adding to the number of languages, religions, ethnic and cultural backgrounds found in Europe and other continents. In Australia, in contrast to many other countries, the diversity of the population was well established and recognised before multiculturalism was first coined in the late 1970s (OMA 1989). However, the response was in the main related to the diversity of the immigrant population minimising significant aspects of diversity such as class, gender and culture and care beyond multiculturalism.This has had enormous implications for nursing and health care (Milner 1993). Today, in addition to 20 surviving Aboriginal dialects, more than one hundred other languages are spoken by people from culturally and linguistically diverse backgrounds (Department of Immigration & Citizenship 2008; Omeri &
AKRAM OMERI Adjunct Associate Professor University of Western Sydney School of Nursing Sydney NSW, Australia
Ahern 1999). Communication between cultures remains a critical issue for the cultural understanding necessary for transcultural nursing practice to be effective. The social and cultural determinants of health is emphasised by Leininger’s Culture Care Theory (Leininger and McFarland, 2002). In more recent years, equal emphasis has been placed on the impact that social and organisational structures have on our health (Papadopoulos 2006). In a diverse world, transcultural nurses strive to make a difference to the health and well being of people, irrespective of their cultural backgrounds transcultural nurse researchers across the world have been and continue to be engaged in the production of knowledge, which has the potential to make a difference for people at whatever point of the health/illness continuum they may be (Omeri 2008; 2002). In order to foster excellence in transcultural nursing practice, the development and wide application of transcultural nursing standards is of paramount importance to advancing excellence in transcultural nursing practice.Work has
Volume 28, Issue 1–2, April 2008
CN
45
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 46
Irena Papadopoulos and Akram Omeri
already been undertaken in this area.The certification of designated transcultural nurses is based upon eight standards developed using Leininger’s Theory of Culture Care Diversity and Universality and Campinha-Bacote’s Model of Cultural Competence (Leininger 1991, 1998, 2006; Campinha-Bacote 2002). Standards provide agreed criteria by which practice may be evaluated and teaching and learning progressed (Andrews & Boyle 2008: 10). It can be argued that transcultural nursing theory and models are the most appropriate for the 21st century, as they cogently address the deficits of the bio-medical model which dominated both medicine and nursing in the 20th century. As the articles in this section demonstrate, transcultural nurses have the knowledge and tools to help them transform nursing and health care in many places in the world. User friendly theoretical frameworks facilitate both the production of knowledge and its application. Marilyn McFarland and Marilyn K Eipperle in their article ‘Culture Care Theory: A proposed theory guide for nurse practitioner practice in primary care settings’ (2008), propose just that. Utilising Leininger’s Theory of Culture Care Diversity and Universality as a foundation, they put forward a guide for educational preparation for advanced practice nurses working in primary care.They demonstrate how through the application of this theory, education, research and practice are connected as essential components toward the provision of culturally congruent care to meet the healthcare needs of diverse individuals, families, groups, and communities by family nurse practitioners.This will go some way towards eliminating the health inequalities experienced by many marginalised communities and individuals. In her article, ‘A partnership of a Catholic faith-based Health system, Nursing and American Indian traditional Indian medicine practitioners’, Ann O Hubbert (2008) uses Leininger’s theory to discuss how the creative thinking and actions 46
CN
Volume 28, Issue 1–2, April 2008
of a group of people resulted in a cultural partnership which bridged the gap between the professionals and the lay people to bring about much needed improvements to the services provided to an American Indian community. We learn that two of the key foundations of the traditional Indian medicine philosophy are, the seven aspects of life and the essence of a holistic individual. Knowing these, helps us understand the personhoods of the people of this community. Amazingly, even though differences exist in human behaviours and actions among cultures, the seven values of the sacred life discussed in this article, are also similar among cultures and different religions.These are respect, honesty, truth, humility, compassion, wisdom and unconditional love. These values are evident in the article ‘Bridging Generic and Professional Care Practices for Muslim Patients Through the use of Leininger’s Culture Care Modes’ by Hiba Webbe-Alamah (2008). Although the five tenets of Islam provide a strong practical framework for everyday living, they too, promote the values of respect, honesty, truth, humility, compassion, wisdom and unconditional love.These values come alive in the descriptions of the many Muslim generic care beliefs and practices provided in this article. Wise use of such information can help nurses provide sensitive and appropriate care. Myrna AA Doumit and Huda Abu-Saad Huijer’ (2008) address the importance of communication and truth telling in their article ‘Lebanese cancer patients: Communication and truth telling’. Notwithstanding the dangers of generalising, it has been the practice in the individualistic ‘West’ to tell the patient their cancer diagnosis. On the other hand much has been published on how families in collectivist societies, such as the Lebanese, prefer to manage such information and request that any such diagnosis is not given to the patient direct.This article challenges that stereotype by providing evidence that the Lebanese patients who participated in this study consider it their right to know their diagnosis and that being more open
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 47
Editorial: Transcultural nursing theory and models about this will improve the levels of communication they have with their families and professional carers. Despite the improvements in people’s health in many countries due to biomedical and biotechnological advancements, huge health inequalities continue to persist both between countries and within countries. The continued development and application of research based Transcultural nursing insights has still a greater contribution to make to the peoples of the world as it realises its potential to contribute to the elimination of health inequalities.
References Andrews M and Boyle J S (2008) Transcultural Concepts in Nursing Care, 5th edn, Lippincott: Philadelphia. Camphina-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: A model of care, Journal of Transcultural Nursing 13: 181–184. Department of Immigration and Citizenship (2008) Australian Government, National Agenda for a Multicultural Australia accessed at http://www .immi.gov.au/media/publications/multicultural/ agenda/agenda89/executive.htm on April 2008. Department of Immigration & Citizenship (2008) Australian Government, National Agenda for a Multicultural Australia accessed at http:// www.immi.gov.au/media/publications/ multicultural/agenda/agenda89/language. htm on April 2008. Doumit MAA and Abu-Saad HH (2008) Lebanese cancer patients: Communication and truth-telling preferences, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 74–82. Hubbert AO (2008) A partnership of a Catholic faith-based health system, nursing and traditional American Indian medicine practitioners, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 64–72. Leininger MM (1991) Culture Care Diversity and Universality:A theory of nursing, National League for Nursing Press: New York. Leininger MM (1998) Twenty-five years of knowledge and practice development transcultural
CN
nursing society annual research conferences, Journal of Transcultural Nursing 9: 72–74. Leininger MM and McFarland MR (eds) (2002) Transcultural Nursing: Concepts,Theories, Research and Practice, 3rd edn, McGraw-Hill: New York. Leininger MM and McFarland MR (2006) Care Diversity and Universality:A worldwide theory for nursing, 2nd edn, Jones & Bartlett: Sudbury. McFarland MM and Eipperle MK (2008) Culture care theory: A proposed practice theory guide for nurse practitioners in primary care settings, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 48–63. Milner A (1993) Beyond culture, beyond multiculturalism, in Clark C, Forbes D and Francis R (eds) Multiculturalism, Difference and Post Modernism, pp 126–139, Longman Cheshire: Melbourne. Office of Multicultural Affairs (1989) National Agenda for a Multicultural Australia, AGPS: Canberra. Omeri A and Ahern M (1999) Utilizing culturally congruent strategies to enhance recruitment and recognition of Australian Indigenous nursing students, Journal of Transcultural Nursing 10: 150–155. Omeri A (2002) Reflections on Australia and transcultural nursing in the new millennium, in Leininger M McFarland M (eds) Transcultural Nursing Concepts,Theories, Research & Practice, 3rd edn, McGraw-Hill: New York. Omeri A (2006) Transcultural nursing: the way to prepare culturally competent practitioners in Australia, in Papadopoulos I (ed), Transcultural Health and Social Care: Development of Culturally Competent Practitioners, Ch 18, Churchill Livingstone Elsevier: Edinburgh. Omeri A (2008) Epilogue: Advancing transcultural nursing through collaboration, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 207–210. Papadopoulos I (Ed) (2006) Transcultural Health and Social Care: Development of culturally competent practitioners, Churchill Livingstone Elsevier: Edinburgh. Wehbe-Alamah H (2008) Bridging generic and professional care practices for Muslim patients through use of Leininger’s culture care modes, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 83–97.
Volume 28, Issue 1–2, April 2008
CN
47
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 48
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 48–63.
Culture care theory: A proposed practice theory guide for nurse practitioners in primary care settings ABSTRACT Key Words advanced practice nursing; Leininger’s culture care theory; culturally congruent care ethnonursing method
Leininger’s Theory of Culture Care Diversity and Universality is presented as a foundational basis for the educational preparation, primary care contextual practice, and outcomes-focused research endeavours of advanced practice nursing. Discussion emphasises the value of care and caring as the essence of advanced practice nursing through the use of three modes of care, use of the Sunrise and other enablers, and the ethnonursing method. Education, research, practice, and key concepts of the theory are connected as essential components toward the provision of culturally congruent care to meet the healthcare needs of diverse individuals, families, groups, and communities by family nurse practitioners. Received 3 October 2007
MARILYN M MCFARLAND School of Nursing University of Michigan Flint MI, USA
‘T
he fate of nursing conceptual models and theories in the contemporary climate of advanced practice nursing’ is a question we have pondered since reading an article by Fawcett, Newman, and McAllister (2004: 136). In their scholarly dialogue, Fawcett et al explored the development and function of advanced practice nursing within the current health care system of the United States and discussed nursing theory in relation to the preparation for and application within the advanced practice role. It is our pro-
48
CN
Volume 28, Issue 1–2, April 2008
Accepted 14 February 2008
CN
MARILYN K EIPPERLE Family Nurse Practitioner Kaleva MI, USA
posal that Leininger’s Theory of Culture Care Diversity and Universality addresses this question by providing an appropriate and useful theoretical framework/conceptual model of nursing for nurse practitioners that informs advanced practice nursing, particularly the nurse practitioner role, to provide culturally congruent care to diverse and similar clients in primary care practice contexts. ‘A framework of advanced practice nursing could guide the development of advanced practice curriculums,
CNJ 28_1_2_internal.qxd
14/07/2008
12:24 PM
Page 49
Practice theory guide for nurse practitioners in primary care settings shape role descriptions and practice agreements, inform policy development related to provider roles in healthcare, and provide direction for research agendas’ (Brown 1998: 157). More specifically, as discussed by Newman and McAllister as above, we are offering the special contributions this theory has been making to the collective knowledge base of advanced practice nursing theory. As Anderson (1987: 7) has stated,‘We need to use a framework for nursing care that allows us to examine the multiple determinants which shape people’s experiences.’ Advanced practice nursing, as defined by Hanson & Hamric (2003: 205) is ‘the application of an expanded range of practical, theoretical, and research-based therapeutics to phenomena experienced by [clients] within a specialised clinical area of the larger discipline of nursing’ with further clarification that the core competency of each role is ‘direct clinical practice’ and that a nurse practitioner is therefore an advanced practice nurse. The focus of this article is to address what has been done toward integrating Leininger’s Theory of Culture Care Diversity and Universality into the practice of advanced practice nursing in the role of the family nurse practitioner (FNP) in primary care contexts; and what, in our view, needs to be done now and in the future to expand the potential role of this theory in nurse practitioner practice. Given that culture care is a core competency domain for family nurse practitioners (United States Department Health and Human Services [DHHS] 2002), it is our view that nurse practitioners need to recognise the need, validity, and missing component of culture care in nursing. Leininger (2006a: 16) refers to culturally congruent care as ‘knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully fit the cultural values, beliefs, and lifeways of clients for their health and well-being, or to prevent illness, disabilities, or death … To provide culturally congruent care and safe care has been the major goal of the Culture Care
CN
Theory.’The major premise of the Culture Care Theory is that there are differences (diversities) and universalities (commonalities or similarities) in transcultural care knowledge and practices that have awaited discovery (and have been discovered) to establish a growing body of relevant transcultural nursing knowledge as the new guide to nursing practices (Leininger 2002b: 79; Omeri 2003: 181). Culture is the history or learned symbolic human and structural organisation and action that make humans human (Keesing 1981 cited in Ray 1999: 178); culture ‘refers to patterned lifeways, values, beliefs, norms, symbols, and practices of individuals, groups, or institutions that are learned, shared, and usually transmitted intergenerationally over time’ (Leininger 2002b: 83). Leininger (2006a: 12) has defined care as ‘those assistive, supportive, and enabling experiences or ideas towards others with evident or anticipated needs to ameliorate or improve a human condition or lifeway ... care has cultural and symbolic meanings such as care as protection, care as respect, and care as presence’ and that caring entails ‘actions, attitudes, and practices to assist or help others toward healing and well-being.’ Culturally congruent care, then, refers to ‘culturally-based care knowledge, acts, and decisions used in sensitive and knowledgeable ways to appropriately and meaningfully to the cultural values, beliefs, and lifeways of clients for their health and well-being, or to prevent illness, disabilities, or death’ (Leininger 2006a: 15). The nurse practitioner needs to be able to sensitively and competently integrate culture care into contextual routines, clinical ways, and approaches to primary care practice through role modeling, policy making, procedural performance and performance evaluation, and the use of the advance practice nursing process. By using Leininger’s Sunrise Enabler (Leininger & McFarland 2006: 25) and the three care modes to guide nursing actions and decisions, we predict the nurse practitioner would be able to provide culturally congruent, safe, meaning-
Volume 28, Issue 1–2, April 2008
CN
49
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 50
Marilyn M McFarland and Marilyn K Eipperle
ful, and beneficial care to clients in primary care contexts (see Appendix I). The six criteria for theory application in advanced practice nursing posited by Newman in Fawcett et al (2004: 136) were that nursing theories applied in advanced practice nursing should: be inclusive rather than exclusive; foster a focus on the whole person rather than the disease or illness; include consideration of the patient’s/family’s/significant other’s perception of the situation; be holistic in nature which is helpful to both practice and documentation; facilitate autonomous nursing practice (aspect of professionalism along with knowledge and service); and, encourage diverse ways of knowing, including empirics, ethics, aesthetics, personal knowing, and sociopolitical knowing (Carper 1978 and White 1995, cited by Fawcett et al 2004: 136). As advanced practice nurses who are highly skilled and educated, nurse practitioners have a moral duty and obligation to use their knowledge and skills in creative ways through nursing actions and decisions to provide culturally competent care in clinical and nonclinical contexts to meet or assist with the diverse needs of all people. ‘[Advanced Practice Nurses] represent the majority of our profession’s most highly educated nurses. It is their responsibility to do more than just render high quality care on a one to one basis with their clients. Rather, they are also accountable for maintaining the systems within which that care occurs’ (Germain 2004: 433). Through the many and various roles that nurse practitioners express their leadership and skills, their nursing perspective influences the actions and decisions of the larger body (group, committee, organisation, institution) in which they are a participant. Thus, culturally congruent care as provided by advanced practice nurses/nurse practitioners should become integrated into the collective worldview of that body and thereby be reflected in their vision, mission, goals and objectives, and ultimately its functionality, actions, and decisions for meeting the needs of the people 50
CN
Volume 28, Issue 1–2, April 2008
for whom it offers assistance. ‘Healthcare organisations should be committed, willing, and supportive of their staff to ensure the attainment of a culturally competent work environment’ (Ndiwane et al 2004).
INCLUSIVE VERSUS EXCLUSIVE Leininger’s Theory of Culture Care Diversity and Universality encompasses all cultures, racial, ethnic, or minority groups and is applicable to subgroups within the dominant societal culture. The focal application of the theory is upon individuals, families, groups, communities, and institutions in diverse health contexts (Leininger 2002b: 80). ‘Culturally based caring is essential to curing and healing, for there can be no curing without caring, but caring can exist without curing … Care is the essence of nursing and a distinct, dominant, central, and unifying focus’ (Leininger 2002b: 79). Leininger extrapolates this further by stating: ‘Care is an essential human need; caring is nursing; caring is the heart and soul of nursing; caring is power; caring is healing; and caring is the distinctive feature that makes nursing what it is or should be as a profession and discipline’ (Leininger & McFarland 2002: 11). This perspective has gained widespread acceptance throughout nursing as shown by the following:‘the development of specific theories focusing on caring in nursing is indicative of the increasing recognition being given to caring as a central concept within the discipline’ [emphasis added] (McCance, McKenna, & Boore 1999: 1394). It is essential for the nurse practitioner in a primary care context to establish a trusting relationship with clients to assist them in their endeavours to prevent and treat disease and move toward health and wellness. Care and caring are cornerstones for developing that trusting relationship. Care, as defined by Leininger (2002a: 11), are those ‘assistive, supportive, enabling, and facilitative culturally-based ways to help people in a compassionate, respectful, and appropriate way to improve a human condition or lifeway or to
CNJ 28_1_2_internal.qxd
30/07/2008
9:47 PM
Page 51
Practice theory guide for nurse practitioners in primary care settings help people face illnesses, death, or disability.’ The nurse practitioner needs to be sensitive to the unique cultural expressions of each individual and family while becoming knowledgeable about the worldview, values, social structure factors, and lifeways of clients and while developing a mutual trust that will facilitate obtaining clinical and nonclinical information that is accurate, congruent, and beneficial through advanced nursing observation and assessment. ‘The culturally competent [Advanced Practice Registered Nurse] is knowledgeable and respectful of diverse cultural beliefs and practices, and partners with the client to develop a care regimen that produces the desired health outcomes within the context of the client’s cultural values’ (Germain 2004: 435). It is imperative that accurate as well as cultural specific information is used to develop the client’s therapeutic regimen through selected methods that are beneficial and acceptable to the client who will implement them. ‘In general, cultural caring rituals of clients and nurses are powerful forces to know, understand, assess, and respectfully use. … Nurses will be expected to incorporate generic rituals into client care for congruent and beneficial care’ (Leininger 2002c: 132). Therefore, care and caring are essential skills for nurse practitioners to develop, express, and sustain with clients throughout each healthcare encounter. ‘Culturally congruent and therapeutic care occurs when culture care values, beliefs, expressions, and patterns are explicitly known and used appropriately, sensitively, and meaningfully with people of diverse or similar cultures’ (Leininger 2006a: 19). The Culture Care Theory provides nurses/ nursing with three modes to assist them in making care regimens meaningful and helpful to clients and through which culturally congruent nursing care actions and decisions to clients can be made. Leininger (2006a: 8) developed the three modes of care, defined and described as: 1. Culture care preservation and-or maintenance: those assistive, supportive, facilitative, or
CN
enabling professional acts or decisions that help cultures retain, preserve, or maintain beneficial care beliefs and values, or to face handicaps or death. 2. Culture care accommodation and-or negotiation: those assistive, supportive, facilitative, or enabling professional acts or decisions that help cultures adapt to or negotiate with others for culturally congruent, safe, and effective care for their health, well-being, or to deal with illness or dying. 3. Culture care restructuring and-or repatterning: those assistive, supportive, facilitative, or enabling professional acts or decisions that help people reorder, change, modify, or restructure their lifeways and institutions for better (or beneficial) healthcare patterns, practices, or outcomes. These modes allow for individualised approaches to care actions and decisions as well as incorporating into nursing practice the diverse ways of knowing within cultures, individuals, groups, communities, or institutions. ‘Inherent in each of these modalities are three of the core values that underlie advanced practice nursing: respect; advocacy; and partnership’ (Germain 2004: 435). Primary care ‘deals with awareness and assessment of the connection between biologic and behavioral life experiences and health and illness. Its major features include the delivery of ‘first contact’ healthcare, comprehensibility, longitudinality, prevention of disease, health promotion, and coordination of care services’ (Starfield 1991 cited by Ray 1999: 177). It is most essential for the nurse practitioner to use the three modes of care and caring with respect for the client’s beliefs, values, and expressions regarding health and well-being and to advocate for the client based on the client’s worldview, and to do so in partnership with the client to ensure that safe, beneficial, and appropriate as well as culturally congruent care actions and decisions are mutually chosen.The nurse practitioner is accountable to the client to reflect
Volume 28, Issue 1–2, April 2008
CN
51
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:24 PM
Page 52
Marilyn M McFarland and Marilyn K Eipperle
back with the client in a continual and confirmatory manner to ensure the client understands and agrees with the chosen care modalities and is willing and able to use them.We (the authors) have used the Culture Care Theory in our own nurse practitioner practices through the use of the three modes of care when establishing a client relationship with individuals, families, groups, or institutions; when considering the manner of assessment to be performed; and, by integrating generic care approaches when mutually establishing plans of care actions and decisions with clients. Using open-ended questions, active listening techniques, and appropriate language and touch are definitive ways to demonstrate caring and facilitate client trust and sharing during the assessment process as well as throughout all phases of the nursing process.
WHOLE PERSON VERSUS DISEASE OR ILLNESS Fawcett et al (2004: 137) state that the: Gestalt that guides NP practice is the ability to see the [client] as a whole and to appreciate that the [client] represents a complex constellation of physical, emotional, psychological, spiritual, social, environmental, and economic life factors that interact and contribute to the person’s unique wholeness and influence their ability to participate in health promotion, health maintenance, and disease modifying actions. The Culture Care Theory factors influencing culture care values, practices, and beliefs and which are embedded in worldview include (but are not limited to) language, philosophy, religion and spirituality, kinship, social, political, legal, educational, economic, technological, ethnohistorical, and environmental context (Leininger 2002b: 79) as is represented by the Sunrise Enabler. ‘The Sunrise Enabler helps nurses to discover and reflect on their decisions and 52
CN
Volume 28, Issue 1–2, April 2008
actions [using the three modes of care action and decision] … and to arrive at the goal of the theory, namely culturally congruent care’ (Hubbert 2006 cited in Leininger & McFarland 2006: 355), and can be more expansively used by nurse practitioners in primary care contexts ‘to show and predict relationships among worldview, sociocultural dimensions, environmental context, language and ethnohistory, diverse health systems and principles, and to guide [advanced practice] nursing actions and decisions’ (Wenger 2006 cited in Leininger & McFarland 2006: 330).The Sunrise Enabler is used by the nurse practitioner in a primary care context to reflect upon the client situation and to develop care actions and decisions when assisting clients toward health and wellness. Client situations may include chronic illnesses such as diabetes, pulmonary disease, dyslipidemia, or hypertension; lifestyle concerns such as alcohol, substance, or tobacco abuse, weight management, growth and development or issues relating to adult stages of life, domestic violence or child abuse, elder care planning or difficulties; family planning; immunizations; and, psychological-mental health matters. The culture care theory guides nurses to use generic or folk care, nursing care, and professional care-cure practices to provide culturally congruent care for well-being, health, growth, and survival and to face handicaps or death (Leininger 2002b: 79). ‘Every human culture has generic (lay, folk, or indigenous) care knowledge and practices and usually professional care knowledge and practices, which vary transculturally and individually’ (Leininger 2002b: 79). Integrating generic and professional care concepts into advanced practice nursing within the nurse practitioner role is essential to achieving beneficial care outcomes for the client. ‘Beneficial, healthy, and satisfying culturally-based care influences the health and well-being of individuals, families, groups, and communities within their environmental context’ (Leininger 2002b: 79).
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 53
Practice theory guide for nurse practitioners in primary care settings
PERCEPTION OF THE SITUATION ‘Cultural conflicts, cultural imposition practices, cultural stresses, and cultural pain reflect the lack of culture care knowledge to provide culturally congruent, responsible, safe, and sensitive care’ (Leininger 2002b: 79).Therefore, it is essential for nurse practitioners to use three modes of care and caring through the perspective of the emic (insider) lens of the client as well as the etic (outsider) lens of the professional clinician/nurse practitioner. According to Leininger (2006a: 14) generic or emic care ‘refers to the learned and transmitted lay, indigenous, traditional, or local folk (emic) knowledge and practices’ and professional or etic care ‘refers to formal and explicit cognitively learned professional care knowledge and practices generally obtained through educational institutions’ and experiences. Some better known generic care practices include ‘low tech’, ‘over the counter’ or ‘home remedy’ approaches used to promote comfort and healing for musculoskeletal aches or minor injuries, sore throats, nasal congestion, earache, or skin rashes. Traditional measures for emotional or psychosocial comfort include spiritual rituals using candles, incense, tobacco, or aromatic oils. Professional acceptance of emic care modes in complement with or in place of or with professional care modes (where safe and appropriate) assist the client in building a trust relationship with the nurse practitioner and helps to promote acceptance of professional care practices. Cultural competence requires: a change in mindset from viewing how clients can fit into the nurses’ world and way of doing things because nurses’ know best (ethnocentrism) to examining how nurses may understand and fit into the patients world, [thus] changing the nurses’ practice recommendations to include those beliefs, traditions, and practices that have worked for the patients (ethnorelativism). (St Clair 1999: 1)
CN
Other factors influencing clients’ views or perceptions in the healthcare encounter include worldview and environmental context. Worldview refers to ‘the way people tend to look out upon the world or their universe to form a picture or value stance about life or the world around them’ (Leininger 2006a: 15).Worldview is the perception of the client. In the healthcare context, worldview influences the client’s understanding of information shared by the nurse practitioner, acceptance of professional care practices, and the client’s willingness and ability to use the methods mutually selected as the ‘plan of care’ (eg ‘fatalism’ may influence the client not to use health promotion or disease prevention practices suggested by the nurse practitioner). Environmental context also has significant influence upon the client’s healthcare practices. Environmental context ‘refers to the totality of an event, situation, or particular experience that gives meaning to people’s expressions, interpretations, and social interactions, and technologic factors in specific cultural settings’ (Leininger 2006a: 15). This holds significance for nurse practitioners in primary care contexts.The ‘setting’ of the office (eg art; literature; ambience/ décor; client flow design/user friendliness; type/content of magazines and teaching literature), languaging of forms, staff composition/ posture/language/tone, and means of meeting and greeting all lend to ‘the totality’ of the primary care experience of the client. The nurse practitioner’s body language, listening skills, approach to assessment and sharing of information, flexibility toward modifying professional practices advised, and attention to privacy and confidentiality during the encounter contribute to the ‘particular experience’ of the client within the environmental context of the primary care setting.These contributing factors in interactive totality influence the client’s perspective of the nurse practitioner, the healthcare encounter, and indeed, the healthcare system, and significantly
Volume 28, Issue 1–2, April 2008
CN
53
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 54
Marilyn M McFarland and Marilyn K Eipperle
affect the individual’s willingness and ability to ethnohistory; kinship and social factors; cultural use the modalities of care mutually chosen as the values, beliefs, and lifeways; religious, spiritual, and philosophical factors; technological factors; ‘plan of care’. economic factors; political and legal factors; Transcultural nurses focus more on human educational factors; language and communicacaring, health, and well-being from an inte- tion factors; professional and generic (folk, lay) grative and holistic perspective … Some- care beliefs and practices; and general and spetimes in helping clients, there needs to cific nursing care factors (Leininger 2006:137). be more emphasis on generic care than on The strength of this enabler is that the nurse professional care modes … such decisions practitioner can obtain holistic assessments to require knowledge of both generic and pro- determine the dominant patterns of caring and fessional practices along with consumer health practices as this influences advanced input. Most importantly, professional nurses practice nursing decision making and action have a societal and legal mandate to always planning (Leininger 2006c: 134). ‘The transcultural nurse is often asked to proinform and share relevant professional knowledge with clients and not neglect generic care tect clients of non-Western cultures who are unfaknowledge to arrive at sound decisions. Tran- miliar with Western medicines and treatments scultural nursing promotes and practices from being demeaned or shunned when using integrative care so that the client gets the their folk remedies. Establishing mutual and better of the two worlds of knowing and genuine relationships between the healthcare therapies. (Leininger 2002d: 148) provider and the client or family is critical to promote beneficial integrative care’ (Leininger 2002d: 151).Therefore, it is imperative for the HOLISTIC IN NATURE Fawcett et al state that nurse practitioners nurse practitioner to embrace the desired attribshould have an ‘awareness of the person’s life utes for integrative care so that culturally confactors’ as guides to formulate a holistic plan of gruent, safe, meaningful and beneficial care can care to assist the person ‘to maintain or regain be provided in primary care contexts. These health by means of comprehensive health main- attributes include trust and mutual respect in tenance, disease prevention, or health restora- caring, healing, curing, and well-being; collabotion.’ Through the use of the Culture Care rative decision making using the best of emic and Theory and the Sunrise Enabler, the totality of etic practices; seeking etic and emic care-cure an individual or group is approached, and serves practices that are congruent, safe, and meaningas ‘a cognitive guide to tease out culture care ful; seeking holistic care perspectives to ensure phenomena from a holistic perspective of multi- safe and congruent generic practices; seeking ple factors that can potentially influence care beneficial care or healing practices that incorand the well-being of people’ (Leininger 2002b: porate the client’s values, beliefs, and lifeways 79). The Acculturation Healthcare and Assess- within their living environments; and seeking ment Guide can be readily incorporated into competent, creative, and compassionate practithe initial as well as maintenance health assess- tioners (Leininger 2002d: 150). ment processes by the family nurse practitioner in the primary care context to assess ‘whether FACILITATE AUTONOMOUS cultural clients are more traditionally or non- NURSING traditionally oriented to their cultures in Autonomous nursing practice in the nurse pracdiverse areas’ (Leininger 2006a: 26, 2006b: 64, titioner role herein means ‘independent, collab2006c: 134). These areas include worldview; orative or consultative practice’ but not isolated 54
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 55
Practice theory guide for nurse practitioners in primary care settings or insular practice.There are many studies in the literature to support the value and contribution of primary care nurse practitioners in providing quality primary care practices to clients (Avron 1991; Birkholtz & Viens 1999, 2001; Brown & Grimes 1995; Capan, Beard, & Mashburn 1993; Hall 1990; Moody, Smith, & Glenn 1999; Mundinger et al 2000; Salkever 1992 cited in Fiandt et al 2002: 14). Nurse practitioners in the United States perform a large percentage of the ‘services’ provided by family practice physicians. Based on outcome studies, nurse practitioners outperform physician providers in the area of health promotion and were more likely to provide care and support for ‘lifestyle management’ through teaching and counseling for concerns such as nutrition, exercise, weight reduction, smoking cessation, growth and development, family planning, and psychosocial needs (Brown & Grimes 1995; Moody, Smith, & Glenn 1999). Through means of the three modes of care as previously described, the family nurse practitioner is able to apply the core competencies and specialty-specific domains of advanced practice in primary care contexts to meet the needs of clients. The Culture Care Theory is a useful framework to guide autonomous advanced nursing practice by guiding assessment of lifestyle, traditional and nontraditional generic care practices, and the non-care practices of individuals, families, groups, or institutions. In 2002, the American Association of Colleges of Nursing (AACN) and the National Organization of Nurse Practitioner Faculties (NONPF) established that ‘All nurse practitioners [are] able to demonstrate these core competencies [upon] graduation’ (DHHS 2002). The Domains and Core Competencies of Nurse Practitioner Practice are presented in Appendix II. Each set of specialty competencies builds upon this set of core competencies and throughout the competencies, client is defined as the individual, family, group, and-or community. Family nurse practitioner competencies include all six of the core competencies with the addi-
CN
tion of the seventh domain of cultural competence as core for the FNP specialty. Similarly, the Australian Nursing and Midwifery Council Incorporated (ANMC) co-commissioned with the Nursing Council of New Zealand in 2004 a review of the scope and role of nurse practitioners.Their efforts resulted in national standards for nurse practitioner practice with supporting performance indicators. In this Nurse Practitioner Competency Framework (refer to Appendix III) it is stated that the nurse practitioner ‘establishes therapeutic links with the patient/ client/community that recognise and respect cultural identity and lifestyle choices’ with one of the three performance indicators being ‘[demonstrating] cultural competence by incorporating cultural beliefs and practices into all interactions and plans for direct and referred care’ (ANMC 2004: 4). Cultural competence, however, is not an area that the family nurse practitioner addresses separately with clients, but rather it is incorporated into the advanced practice approaches taken for each of the core competencies. In other words, cultural competence is integrated into nurse practitioner practice nursing assessment and care actions and decisions in the primary care context through the situationally appropriate use of the three care action modes previously described and discussed. Being culturally competent, for example, is vital for establishing the nurse practitioner–client relationship, for effectiveness in the teaching–coaching role, or when assisting clients to manage or negotiate the healthcare delivery system.
DIVERSE WAYS OF KNOWING Culturally congruent care incorporates diverse ways of knowing which are derived from the perspective or worldview of the individual, family, group, community, or institution. ‘The assumption that the theory only focuses on the culture of the ‘other’… is inaccurate. Implementing the theory into practice stimulates nurses, as carers and researchers, to reflect upon
Volume 28, Issue 1–2, April 2008
CN
55
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 56
Marilyn M McFarland and Marilyn K Eipperle
their own cultural values and beliefs and how they may influence the provision of care’ (Leininger & McFarland 2002 and Omeri 1996, 1997 cited in Omeri 2003: 181). In their study, Fiandt et al (2002) explored three aspects of nurse practitioner practice when viewed as complementary to physician practice: use of the nursing model; identification of the vulnerable characteristics of clients; and health promotion activities. For our purposes, we will focus on the first and third parameters.‘Although nurse practitioner education is embedded in a nursing model, research data describing nurse practitioner practice have been insufficient to clearly characterise and differentiate nurse practitioner practice from that of primary care physicians and physician assistants.The complementary nature of nurse practitioner practice, although addressed in theory in education literature, is not reflected in the research describing nurse practitioner practice. Research detailing the complementary aspects of nurse practitioner nursing based on a nursing model [such as the Culture Care Theory] is needed to support nurse practitioner theory and education and to influence healthcare policy’ (Fiandt et al 2002: 14). Globally, national nursing accreditation bodies have called for the integration of cultural learning in nursing education. The (Australian) National Review of Nursing Education Multicultural Nursing Education (Eisenbruch 2002) recommended the following strategies for the enhancement of nursing cultural competence, stating that the profession needed to address the following concerns: the need for a multicultural framework in nursing education; the impact of multicultural nursing practice in a diverse nation; the increasing lifelong awareness of the sociopolitical and economic context of culture and health in developing culturally competent care; the appropriate representation of culture in education and practice to suit the community; partnerships between education and practice; systematic investigation into the cultural needs of students, staff, and clients; recruitment and 56
CN
Volume 28, Issue 1–2, April 2008
retention of both Indigenous nurses and nurses from culturally and linguistically diverse backgrounds; attention to the employment of overseas-qualified nurses; and, questions relating to multidisciplinary research (Omeri 2003: 180). In the United States, the AACN document of October 2006 presents eight Essentials of Doctoral Education for Advanced Nursing Practice. These essentials of Doctorate of Nursing Practice (DNP) education are to focus the educator and student toward meeting three goals in preparing them as graduates for practice. One of the three goals is to use science-based theories and concepts to determine the nature and significance of health and healthcare delivery phenomena; describe the actions and advanced strategies to enhance, alleviate, and ameliorate health and healthcare delivery phenomena as appropriate; and evaluate outcomes. Research is a key component in developing nursing knowledge and thereby a key component of diverse ways of knowing. The broad scope of the Culture Care Theory is reflected in Leininger’s definition of nursing which presents nursing as a ‘learned humanistic and scientific profession and discipline which is focused on human care phenomena and activities in order to assist, support, facilitate, or enable individuals or groups to maintain or regain their well-being (or health), in culturally meaningful and beneficial ways or to help people face handicaps or death (Leininger 1991 cited by Leininger 2006a in Leininger & McFarland 2006: 7).The ethnonursing method was developed to study specific nursing care phenomena as well as the Culture Care Theory.The central purpose of the ethnonursing method is to tease out complex, elusive, and largely unknown nursing dimensions [of care] from the people’s focal viewpoints regarding human care, well-being, health, and environmental influences. The ethnonursing method assists in discovering differences between generic or naturalistic care and professional nursing care. Discovering generic or naturalistic or folk care is essential to know and
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 57
Practice theory guide for nurse practitioners in primary care settings use to provide professional nursing care and especially to providing advanced practice nursing care offered by nurse practitioners. When Leininger studied the Gadsup of New Guinea in the 1960s, she found the use of the terms emic and etic useful (as previously defined herein) in studying care and other nursing phenomena.The use of these terms assisted Leininger to discover the diverse meanings and ideas of the people regarding the values, beliefs, and nursing rituals and symbols of care, health and illness. In this first ethnonursing study, Leininger began to develop several enabling guides, such as the Sunrise Enabler and the Observation-ParticipationReflection (OPR) Enabler to help her study the lifeways of the people of the Eastern Highlands of New Guinea (Leininger 2006a: 26). Leininger realised that the ethnonursing method was important to discover caring modes such as the care and feeding of infants, dealing with pain and anxiety, supporting people in lifecycle events and crises, and finding different ways to teach people about how to maintain health, and has suggested that many techniques and enabling guides developed for use with the ethnonursing method can be used by the clinician (Leininger & McFarland 2006: 51). For instance, the Stranger to Trusted Friend Enabler can assist the clinician to move from a Distrusted Stranger to a Trusted Friend to establish favorable relationships with clients (Leininger 2006a: 26). We offer that this enabler can be used by the nurse practitioner to gauge whether the client ‘trusts’ the nurse practitioner and is working ‘with’ the nurse practitioner to share essential health information regarding the his/her lifeways including culturally sensitive health practices such as complementary therapies or folk remedies, nutritional regimes and supplementation, spiritually based rituals, and sensitive information regarding sexual practices or non-therapeutic activities (such as illicit drug use or abuse of prescribed narcotics, for example). The OPR guides researchers and clinicians to devote a period of time making observations
CN
before becoming an active participant in the research or clinical process.The reflective phase provides an opportunity to obtain important and confirmatory data from the people. The guide can be adapted for use to assist the nurse practitioner in client encounters in direct clinical practice contexts. Leininger (2006b: 60) implies such use of this enabler when she states, ‘These phases were expressly conceptualized and developed to fit with the people centered nursing ways that professional nurses are expected to work within their daily experiences.’ For example, the nurse practitioner observing the client sitting in the waiting room and walking down the hall to the examination room presents a valuable opportunity to assess general appearance, gait, pain expressions, tobacco or alcohol use, cultural or non-contemporary forms of dress, use of language, and individual means of contextualising the reason or purpose of the healthcare visit. A period of meeting, greeting, and visiting with the client in the examination room is essential to allow the nurse practitioner sufficient time for further observation while assisting the client to become more comfortable with the situation, thus enabling the nurse practitioner to obtain a more accurate health history and physical assessment. Reflection is also a valuable part of the nursing process as the nurse practitioner clarifies valuable information in reflecting findings back with the client and confirming acceptability and understanding of the diagnostic findings and plan of care with the client.
CONCLUSIONS The Theory of Culture Care Diversity and Universality is inherently structured to provide the advanced practice nurse with a sound theoretical basis for doctoral education, evidence-based research, and primary care practice in the nurse practitioner role. The key components of the Culture Care Theory can be readily linked to the eight Essentials of Doctoral Education for DNP as posited by AACN in their October
Volume 28, Issue 1–2, April 2008
CN
57
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 58
Marilyn M McFarland and Marilyn K Eipperle
2006 document which are: Scientific Underpinnings for Practice; Organizational and Systems Leadership for Quality Improvement and Systems Thinking; Clinical Scholarship and Analytical Methods for Evidence Based Practice; Information Systems/Technology and Patient Care Technology for the Improvement and Transformation of Healthcare; Healthcare Policy and Advocacy for Healthcare; Interprofessional Collaboration for Improving Patient and Population Health Outcomes; Clinical Prevention and Population Health for Improving the Nation’s Health; and Advanced Nursing Practice.These essentials of DNP education will be critical to guiding the process of meeting the three primary goals toward preparing graduates for advanced nursing practice, which are to: 1. Integrate nursing science with knowledge from ethics, biophysical, psychosocial, analytical, and organizational sciences as the basis for the highest level of nursing practice; 2. Use science-based theories and concepts [such as culture care] to determine the nature and significance of health and healthcare delivery phenomena; describe the actions and advanced strategies [such as the three care modes] to enhance, alleviate, and ameliorate health and healthcare delivery phenomena as appropriate; and, evaluate outcomes; and 3. Develop and evaluate new practice approaches based on nursing theories [such as the Culture Care Theory] and theories from other disciplines. (AACN 2006: 9) Doctorate of Nursing Practice (DNP) evidencebased projects will create new nursing knowledge for both the discipline and practice of the profession of advanced practice nursing as well as provide a basis for advancement of the nurse practitioner role. DNP degree programs will foster and accelerate practice focused/outcomes implementation projects that involve critical appraisal and use of existing nursing 58
CN
Volume 28, Issue 1–2, April 2008
knowledge to formulate or reformulate practice guidelines for implementation into practice. Implementation of such practice focused research projects within a nursing conceptual framework such as the Culture Care Theory with the ethnonursing method facilitates building a body of nursing knowledge and ‘practice guided by the concepts of a conceptual model of nursing [which] is more appropriate for advanced practice nursing than a disease treatment model’ (Fawcett et al 2004: 137). Nurse practitioners are endeavoring to comprehend and integrate culture care precepts into practice, but they need more education about culture care and their education needs to be integral to their generic (ASN, BSN) (early professional education and clinical) learning processes because change is easiest when it starts at the beginning. In a recent unpublished pilot study by Mixer (2006), the researcher found that while nursing faculty valued cultural diversity, provided and encouraged clinical experiences with opportunities for students to care for culturally diverse clients, and role modeled culturally sensitive awareness behaviors, the faculty did not use any formal conceptual nursing model or theory (such as the Culture Care Theory) as a basis for their teachings. Family nurse practitioners practicing in primary care contexts need to broaden their practice by also demonstrating leadership in the community as a means toward developing a wider system of caring and healing locally, nationally, and globally. The Theory of Culture Care Diversity and Universality provides a sound basis upon which the nurse practitioner can develop informational systems, bridge cultural gaps, and develop community/group/family consensus. Community leadership can be exercised by participation in school health programs and teaching, and by becoming a member of the local school board, or by offering community-based health education presentations either independently or through other local healthcare agencies such as hospitals, senior living centres or senior com-
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 59
Practice theory guide for nurse practitioners in primary care settings munity/day care centres, or nursing agencies; by offering to assist or present health programs to adult education programs; by participation in literacy programs as a mentor (as literacy is a direct indicator of community health); through local government participation or activism; by becoming involved in eldercare and-or parish health programs, community mental health programs or governing boards; and assisting in the promotion of lay participation in healthcare (such as migrant, community mental health, library, hospital, and district health department boards or lay care services), and lay-professional jointly presented health education events (health fairs or screenings, blood drives), health programs (teen pregnancy, doula, drug or STI prevention) or culturally-based community or education programs or events (eg, tribal powwow, Cinco de Mayo celebrations, African American Heritage events); and communitybased culture care research projects. Participation in professional organisations is also important to foster the development of the profession. Organisations such as the Transcultural Nursing Society, American Nurses’ Association, National Organization of Nurse Practitioner Faculties, Michigan Council of Nurse Practitioners, Michigan Nurses’ Association, American College of Nurse Practitioners, and the American Association of Nurse Practitioners, and other state, regional, national, and international nursing groups have ongoing projects and programs directed toward fostering improved client care as well as the betterment of the nursing profession through education, political or government activism, or policy enactment efforts. We (the authors) propose these outcomes can be achieved through clinical, educational, and research applications of the theory of Culture Care Diversity and Universality with the use of three modes of care and the Sunrise Enabler and the ethnonursing research method. Many theories guide nursing education and research but we propose that the Culture Care
CN
Theory can guide advanced nursing practice and education as well as practice/outcomes based research that is focused on implementing evidence-based research findings to achieve the most safe, beneficial, and satisfying healthcare outcomes. Putting theory into practice entails the element of the theory, in addition to an information gathering process; knowledge of culture and care practices; planning of healthcare; assessment; research; and establishing a caring healing system (Germain 2004: 441–442). Thus, the Theory of Culture Care Universality and Diversity guides advanced nursing practice by: • framing knowledge and predicting similarities and differences among and between cultures; • providing a means to learn and gather care information about cultures essential for holistic assessment and sound nursing conclusions; • discovery of caring and healing values, beliefs, and practices used by individuals, families, groups; • collaboratively using Leininger’s three modes of care; using ethical reasoning, analysis, skill, and decision making relevant to culture; • evaluation through reflective and informed practice which is critical to determine outcome impact and establish accountability, responsibility, and demonstrated practice stewardship; research which is foundational to the nursing discipline’s body of knowledge, core values, and to facilitate contributions to the greater good of society and community, and to advance the art and science of nursing profession; and • establishing and maintaining a system of caring and healing system which is essential for holistic assessment, sound nursing conclusions, and appropriate and integrated care.
Acknowledgements The authors wish to gratefully acknowledge the theoretical contributions of Dr Madeleine Leininger with appreciation for her ongoing support. Volume 28, Issue 1–2, April 2008
CN
59
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 60
Marilyn M McFarland and Marilyn K Eipperle
References American Association of Colleges of Nursing (2006) The Essentials of Doctoral Education for Advanced Nursing Practice, AACN,Washington, DC. Anderson JM (1987) The cultural context of caring, Canadian Critical Care Nursing Journal 4: 7–13. Australian Nursing and Midwifery Council (ANMC) and Nursing Council of New Zealand (2004) National Competency Standards for the Nurse Practitioner, accessed at www .anmc.org.au on October 4, 2007. Avron J (1991) The neglected history and therapeutic choices for abdominal pain: A nationwide survey of 799 physicians and nurses, Archives of Internal Medicine 151: 694–698. Birkholtz G and Viens D (1999) Medicaid claims data comparisons for nurse practitioners, physicians assistants, and primary care physicians in New Mexico, Journal of the American Academy of Nurse Practitioners 11: 3–10. Birkholtz G and Viens D (2001) Developing research methodologies to compare primary care nurse practitioners and physician practices, The American Journal for Nurse Practitioners: 9–10, 13–14, 17–18, 27–28, 31–32. Brown S (1998) A framework for advanced practice nursing, Journal of Professional Nursing 14: 157–164. Brown S and Grimes D (1995) A meta-analysis of nurse practitioners and nurse midwives in primary care, Nursing Research 44: 332–339. Carper BA (1978) Fundamental patterns of knowing in nursing, Advances in Nursing Science 1: 13–23. Capan P, Beard M and Mashburn M (1993) Nurse managed clinics provide access and improve care, Nurse Practitioner 18: 50–55. Eisenbruch M, Rotem A,Waters D, Snodgrass R and Creegan R (2002) Nursing Education in a Multicultural Context. Commonwealth Department of Education, Science, and Training, Canberra, Australia, online ISBN 060
CN
Volume 28, Issue 1–2, April 2008
642-777246-0, accessed at www.dest.gov.au /archive/highered/nursing/pubs/multi_ cultural/1.htm on 06 March 2008. Fawcett J, Newman DML and McAllister D (2004) Advanced practice nursing and conceptual models of nursing, Nursing Science Quarterly 17: 135–138. Fiandt K, Laux CA, Sarver NL and Sayer RJ (2002) Finding the nurse in nurse practitioner practice: A pilot study of rural family nurse practitioner practice, Clinical Excellence for Nurse Practitioners 5: 13–21. Germain M (2004) A cultural variable in practice, cited in Joel LA (ed) Advanced Nursing Practice: Essentials of Role Development, pp 430– 453. FA Davis & Company, Philadelphia, PA. Hall J (1990) Performance quality, gender, and professional role: A study of physicians and nonphysicians in 16 ambulatory practices, Medical Practice 28: 489–501. Hanson CM and Hamric AB (2003) Reflections on the continuing evolution of advanced practice nursing, Nursing Outlook 51: 203–211. Hubbert A O (2006) Application of the culture care theory for clinical nurse administrators and managers, cited in Leininger MM and McFarland MR (eds) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, pp 355, Jones and Bartlett, Sudbury, MA. Keesing R (1981) Cultural Anthropology, Holt, Rinehart & Winston, New York, NY. Leininger M (1991) Culture Care Diversity and Universality:Theory of nursing, National League for Nursing, New York. Leininger M (2002a) Transcultural nursing and globalization of healthcare: Importance, focus, and historical aspects, cited in Leininger M and McFarland MR (eds) Transcultural Nursing: Concepts, theories, research and practice, 3rd edn, pp 3–43, McGraw-Hill Medical Publishing Division, New York. Leininger M (2002b) Part I:The theory of culture care and the ethnonursing research method, cited in Leininger M and McFarland
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 61
Practice theory guide for nurse practitioners in primary care settings M R (eds) Transcultural Nursing: Concepts, theories, research and practice, 3rd edn, pp 71–98, McGraw-Hill Medical Publishing Division, New York. Leininger M (2002c) Culture care practices for congruent competency practices, cited in Leininger M and McFarland MR (eds) Transcultural Nursing: Concepts, theories, research and practice, 3rd edn, pp 117–143, McGrawHill Medical Publishing Division, New York. Leininger M (2002d) Part 1:Toward integrative generic and professional healthcare, cited in Leininger M and McFarland M R (eds) Transcultural Nursing: Concepts, theories, research and practice, 3rd edn, pp 145–154, McGraw-Hill Medical Publishing Division, New York. Leininger MM (2006a) Culture care diversity and universality theory and evolution of the ethnonursing method, in Leininger MM and McFarland MR (eds) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, pp 1–41, Jones and Bartlett, Sudbury, MA. Leininger MM (2006b) Ethnonursing research method and enablers, in Leininger M M and McFarland MR (eds) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, pp 43–81, Jones and Bartlett, Sudbury, MA. Leininger MM (2006c) Culture care of the Gadsup Akuna of the Eastern highlands of New Guinea: First transcultural nursing study (revised reprint), in Leininger MM and McFarland MR (eds) Culture Care Diversity and Universality:AWorldwide Theory of Nursing, 2nd edn, pp 115–157, Jones and Bartlett, Sudbury, MA. Leininger MM and McFarland MR (eds) (2002) Transcultural Nursing: Concepts,Theories, Research and Practice, 3rd edn, McGraw-Hill Medical Publishing Division, New York, NY. Leininger MM and McFarland MR (eds) (2006) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, Jones and Bartlett, Sudbury, MA.
CN
McCance TV, McKenna HP and Boore JRP (1999) Caring:Theoretical perspectives of relevance to nursing, Journal of Advanced Nursing 30: 1388–1395. Mixer S (2006) Faculty expressions, patterns, and practices related to teaching culture care. Unpublished pilot study, Duquesne University, Pittsburgh, PA. Moody N, Smith P and Glenn L (1999) Client characteristics and practice patterns of nurse practitioners and physicians, Nurse Practitioner 24: 94–96, 99–100, 102–103. Mundinger MO, Kane RL, Lenz ER,Totten AM, Tsai WY, Cleary PD, Friedwald WT, Siu AL and Shelanski ML (2000) Primary care outcomes in patients treated by nurse practitioners or physicians, Journal of the American Medical Association 283: 59–68. Ndiwane A, Miller KH, Bonner A, Imperio K, Matzo M, McNeal G, Amertil N and Feldman Z (2004) Enhancing cultural competencies of advanced practice nurses: Healthcare challenges in the twenty first century, Journal of Cultural Diversity 11: 118. Omeri A (2003) Meeting diversity challenges: Pathway of ‘advanced’ transcultural nursing practice in Australia, Advances in Contemporary Transcultural Nursing 15: 175–186. Ray M (1999) Transcultural nursing in primary health care, National Academies of Practice Forum 1: 177–182. St Clair A (1999) Preparing culturally competent practitioners, Journal of Nursing Education 38: 228–234. Salkever DS (1992) Episode based efficiency comparisons between physicians and nurse practitioners, Medical Care 20: 145–153. Starfield B (1991) Innovative ways to study primary care using traditional methods cited in Norton P, Stewart M,Tudiver F, Bass M and Dunn E (eds), Primary Care Research, pp 26–39, Sage, Newbury Park, CA. United States Department of Health and Human Services (2002) Nurse practitioner primary care competencies in specialty areas:
Volume 28, Issue 1–2, April 2008
CN
61
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 62
Marilyn M McFarland and Marilyn K Eipperle
Adult, family, gerontological, pediatric, and women’s health. Health Resources and Services Adminstration, Bureau of Health Professions Division of Nursing, submitted by The National Organization of Nurse Practitioner Faculties (NONPF) in partnership with The American Association of Colleges of Nursing (AACN). Wenger AFZ (2006) Culture care and health of APPENDIX I: LEININGER’S SUNRISE ENABLER
TO
Russian and Vietnamese refugee communities in the United States, cited in Leininger M and McFarland M (eds) Culture Care Diversity and Universality:A Worldwide Theory of Nursing, 2nd edn, pp 355. Jones and Bartlett, Sudbury, MA. White J (1995) Patterns of knowing: Review, critique, and update, Advances in Nursing Science 17(4): 73–86.
DISCOVER CULTURE CARE
Source: Sunrise Enabler © Used by permission of M Leininger.
62
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 63
CN
Practice theory guide for nurse practitioners in primary care settings APPENDIX II: NURSE PRACTITIONER COMPETENCIES Domain 1.
Management of Patient Health/ Illness Status A. Health Promotion/Health Protection and Disease Prevention i. Assessment of Health Status ii. Diagnosis of Health Status iii. Plan of Care and Implementation of Treatment B. Management of Patient Illness
Domain 2. Domain 3. Domain 4. Domain 5. Domain 6. Domain 7.
The Nurse Practitioner–Patient Relationship The Teaching–Coaching Function Professional Role Managing and Negotiating Health Care Delivery Systems Monitoring and Ensuring the Quality of Health Care Practice Cultural Competence
Source: United States Department of Health and Human Services 2002.
APPENDIX III: NURSE PRACTITIONER COMPETENCY FRAMEWORK Standard I:
Dynamic practice that incorporates application of high level knowledge and skills in extended practice across stable, unpredictable, and complex situations. Standard II: Professional efficacy whereby practice is structured in a nursing model and enhanced by autonomy and accountability. Competency 2.2: Establishes therapeutic links with the patient/client/community that recognise and respect cultural identity and lifestyle choices. Standard III: Clinical leadership that influences and progresses clinical care, policy, and collaboration through all levels of health service. Source: Australian Nursing and Midwifery Council (ANMC), Nursing Council of New Zealand 2004.
** NOW AVAILABLE **
S OCIAL E QUITY
AND
H EALTH
Edited by Toni Schofield (University of Sydney) and Olle Lundberg (Centre for Health Equity Studies, Karolinska Institute, Stockholm) A special issue of Health Sociology Review (ISSN 1446-1242) volume 16 issue 2 (2007) This issue focuses on one of the most pressing issues of global health governance – health inequities or inequalities – explored from diverse methodological perspectives and national settings in Australia, Bulgaria, Canada, India, Norway and the USA. Entrenched social divisions and differences and the local, contingent character of health inequity demand close social investigation to underpin effective intervention through public policy. • Editorial — Toni Schofield • Health inequity and women’s self-help groups in India: The role of caste and class — Anant Kumar • Gender, equity and tobacco control — • Social capital, health and electronic community Lorraine Greaves in public high-rise estates: An Australian casestudy — Liza Hopkins • On the inequitable impact of universal health insurance: The experience of Bulgaria in • The impact of household type on adolescent transition — Stephanie D. Short, Valentin women’s well-being in Kenya — Anne M. Dimitrov Hadjiev, Zdravka Dimitrova Toneva Dannerbeck, Andrew Muriuki • Health inequity and its social determinants: • Educational inequalities in avoidable deaths in A sociological commentary — Toni Schofield Norway: A population based study — Espen Dahl, Dag Hofoss, Jon Ivar Elstad • Book Reviews Course Coordinators are invited to contact the Publisher for an adoption evaluation copy. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
e C ontent
PTY
management LTD
Volume 28, Issue 1–2, April 2008
CN
63
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 64
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 64–72.
A partnership of a Catholic faith-based health system, nursing and traditional American Indian medicine practitioners ABSTRACT
Key Words transcultural nursing; Culture Care Theory; Traditional Indian Medicine; American Indian; spirituality in healthcare
The paper presents a historically unique partnership between an American Southwestern, Catholic faith-based, urban hospital and a program it sponsored on the spirituality of American Indian Traditional Indian Medicine (TIM) by a Comanche medicine man. A discussion is offered on the cultural partnerships, experiences and benefits achieved through the cultural accommodations of these spiritual beliefs and practices within this healthcare system. The theory of Culture Care Diversity and Universality (Culture Care Theory), including the Sunrise Enabler, is applied in discussion of these past experiences to explore the relationships among and between the participating cultures.The intent of the partnerships within this program was not to ‘learn Indian healing ceremonies’ but to share the philosophy of TIM with all people (clients and professionals) as a means to enhance their own way of living. Examples of actual nursing decisions and actions are provided including outcomes from the program within the healthcare system and globally. Received 16 July 2007
ANN O HUBBERT Associate Professor University of Nevada Reno NV, USA
H
ealthcare systems are increasingly adapting their services and programs to comply with global trends toward providing cultural care accommodation for culturally diverse client populations and professionals. The purpose of this paper is to present a historical dis64
CN
Volume 28, Issue 1–2, April 2008
Accepted 25 March 2008
CN
cussion of the past experiences from one Catholic faith-based urban hospital in the American Southwest regarding the accommodation of the spiritual beliefs and practices of American Indian (Native American/Alaska Native) clients and staff who were practicing traditional Indian medicine (TIM). These experiences may hold possible applications for other healthcare systems in the United States and-or Australia which are both facing current challenges to provide culturally sensitive care for increasingly diverse patient populations. In Australia, nurses have been encouraged to learn about providing culturally appropriate and safe nursing care for the Australian Indigenous peoples, Aborigines and Torres Strait Islanders, with an open minded
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 65
A partnership of practitioners approach (Goold 2001). In both the United States and Australia, nurses are urged to examine their own beliefs and philosophy of life as a basis for understanding and practicing culturally sensitive care. In addition, the foundation of Leininger’s (1988; 2006) theory of Culture Care Diversity and Universality (Culture Care Theory) is applied as a framework for the discussion of these experiences and the partnerships created among and between the cultures of the TIM practitioners (referred to as traditional Indian medicine people), the Southwestern American Indian clients, nursing and other healthcare providers, and the Catholic faithbased healthcare system which was the main source of hospital and professional healthcare services in the region.
BACKGROUND The United States (USA) population is becoming progressively more diverse (Office of Minority Health 2001; US Census Bureau 2000a); by 2010, minority cultures (non-EuroAmerican lineage) will represent 32% of the national population, increasing to 50% by the year 2050. In the 2000 Census, 4.3 million people (or 1.5 % of the total US population) self identified as American Indian or Alaska Native (United States Census 2000b). This number included 2.4 million people (or 1%) who reported American Indian or Alaska Native as their sole race. Therefore, healthcare systems and professionals are being challenged to provide diverse populations with culturally competent nursing and health skills as part of their healthcare services. Federal healthcare regulatory standards under the Department of Health and Human Services, Office of Minority Health (2001), designated the Nationally Culturally and Linguistically Appropriate Services (CLAS) standards for healthcare in order to support a more consistent and comprehensive approach to cultural and linguistic competence in services and to decrease healthcare disparities. Many healthcare systems
CN
are addressing the standards, which are also interpreted to include the provision of opportunities for culturally specific spiritual accommodations. In addition, the interest among Western healthcare providers about traditional, Indigenous practices among shamans or healers continues to grow (Leininger 2002a: 145). As nurses are the largest group of healthcare providers, they have the opportunities to incorporate culturally sensitive and congruent care to meet the CLAS standards, into their daily practices. Healthcare systems consist of a vast array of cultures and subcultures among and between the client populations, employees, professional disciplines, and the organisational structures, and yet they have historically functioned with ‘unicultural’ views and policies (Gardenswartz & Rowe 1998; Gropper 1996; Leininger 1997). Acknowledgment of the existence of many healthcare systems’ unicultural perspectives, including ethnocentric views (knowing what is best), leading to ethnocentric actions (having the best decisions), is a positive step to include new actions that enhance culturally sensitive care (Leininger 2002b: 50–51, 2006: 53–54). The normal perspective within Western healthcare is the belief that academic, scientific healthcare is superior to cultures’ folk or traditional healthcare beliefs, values, and practices (Leininger 1991). As a result, various aspects of healthcare policies and actions are based on healthcare teams’ preconceived judgments of what will be best for clients based on diagnoses without consideration of cultural beliefs, values, and practices. The American Indians are often included in this approach, as nurses are challenged to remain open-minded, non-judgmental, and non-ethnocentric (Weaver 1999: 201). American Indians have rarely divulged their participation in TIM, including assistance from a traditional medicine person, when they participate in Western healthcare (Struthers, Lauderdale, Nichols & Strickland 2005; Tom-Orme 2002).Their cultural practices have been regarded as private and often disregarded by their
Volume 28, Issue 1–2, April 2008
CN
65
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 66
Ann O Hubbert
Western healthcare providers. As a result, they have often been unable to ‘partner’ the two perspectives of healthcare together in a beneficial holistic approach to their health and lives. The United States Department of Health and Human Services, Indian Health Service (2007), defines a practitioner of Traditional Indian Medicine as ‘a person who is trained in a Native American community, and applies culturally specific knowledge and skills in the diagnosis, treatment, or referral of patients to promote their wellbeing physically, mentally, socially, and spiritually.’ The term ‘spiritual’ has a broad meaning in American Indian culture, unlike the common Western allocation of a patient’s ‘spiritual preference/religion.’ In Traditional Indian Medicine (Garrett & Garrett 1996; Monetathchi 1988a; Ortega 1989) spirit refers to the active flow of energy that connects all living things to ‘God, the Universal Energy/Source, or Great Spirit,’ and spiritual refers to a way of living. An American Indian’s cultural and spiritual behaviors, such as dropping their eyes as a sign of respect, or a period of silence before responding when asked a question (Garrett & Garrett 1996; Monetathchi 1988b; Tom-Orme 2002) could also lead a healthcare provider to make an inaccurate or inappropriate assessment or diagnosis (Gardenswartz & Rowe 1998; Leininger 1997). For example, an Indian patient who does not look directly at the nurse could be perceived by the nurse as ‘not listening to me’ or as ‘non-compliant.’ In turn, these cultural interactions and relationships may contribute to cultural impositions (Leininger 2002b: 51) in which the healthcare professionals are seen by patients as being in authority and thus holding a large amount of power, influence, and authority over them. An example offered by Monetathchi (1988a) is in the frequent subtle language often used by nurses, ‘my client/patient’ or ‘the diabetic.’ Implicit can be the ethnocentrism that the nurse is ‘better than the individual’ (who is the client) or as ‘expressing ownership’ versus using the language of respect and partnership, 66
CN
Volume 28, Issue 1–2, April 2008
for example, ‘Mrs Delores, the client/patient with whom I am working.’
One healthcare system’s environment and process with traditional Indian medicine A historical discussion is offered of the challenges faced and the benefits gained by this individual Catholic faith-based healthcare system, nurses, and employees when they sought to offer culturally sensitive accommodations for the spiritual practices of American Indians clients and employees. The goals for this quest were guided by the mission of the system to provide for the healthcare needs of our community; to embrace the whole person, in mind, body, and spirit; and to serve all people with dignity (Carondelet Health Network 2008; Carondelet Health Services 1986). The healthcare system and providers’ challenges included the following (Hubbert 2004): 1. Acknowledgement that TIM spiritual beliefs and practices are integrated with the healing process; 2. Discovering how specific spiritual practices could be addressed in nursing assessments; 3. Negotiating for physical space accommodations to be made for some spiritual practices; 4. Welcoming the presence of spiritual practitioners; and 5. Blending the cultural spiritual practices of patients with the cultures of nursing and other healthcare professionals. The identified challenges were explored and approached with a unique cultural program over a period of six years from 1984 to 1990. The program, which was internationally attended, began because an Apache nurse recognised that many clients of the Southwestern American Indian nations (Tohono O’odam, Pasqua-Yaqui, Navajo/Dine’, Apache, to name a few) were often entering an ‘unknown culture’ as inpatients of a Catholic faith-based healthcare system. She requested nursing administration to
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 67
A partnership of practitioners provide an educational workshop for the nursing and interdisciplinary staff to increase their cultural sensitivity of American Indian spirituality practices.This led to development of a guiding team that included a nurse, a nursing administrator and a nurse-member of the Catholic religious community who served as a liaison to fulfill the faith-based mission of programs. The three members of the guiding team acknowledged their learning process about cultural/spiritual practices, beliefs, and values of Indian cultures would involve self-discovery through reflection and re-assessment of their own beliefs and values. They sought a partnership with the Indian Health Service (IHS); a Comanche medicine man responded to their request for assistance. Educated at Harvard University, Mr Edgar Monetathchi Jr was the national traditional Indian medicine specialist for the IHS (Monetathchi, 1982). He agreed to guide and facilitate the guiding team’s quest toward ‘accommodating increased spirituality in healthcare and healing. The cultural sharing among and between the cultures of these four individuals, IHS and the individual healthcare system evolved into a program of thirty-six conferences entitled Traditional Indian Medicine: Spirituality and Healing in Today’s Health System which were five to seven days in length.The programs were attended by over 7000 international lay and professional attendees.These conferences were coordinated and taught by the medicine man director and a team of traditional Indian medicine people.The American Catholic Health Association recognised this program with their annual achievement citation for ‘bold and innovative initiatives from Catholic healthcare providers in service to their communities’ (Carondelet Health Services: 1986). Creative, unique partnerships had been formed that worked together to establish integrated care relationships among and between the cultures of the American Indians and their traditional Indian medicine, Catholic faithbased healthcare, nursing, and other healthcare
CN
professionals. Further recognition was given by the chief executive officer and member of the Catholic religious community, Sister St. Joan Willert, when she acknowledged that the original intent had been purely educational to ‘learn about’ the Indian approach to sickness and healing, but the healthcare providers soon realised the ‘many benefits we had [gained] learning this way of life based on respect and unconditional love’ (Carondelet Health Services 1986). In another unique action, this Catholic healthcare system subsequently hired the Comanche medicine man as a full-time TIM specialist upon his retirement from IHS.
CONTEXT OF ADDRESSING TRADITIONAL INDIAN MEDICINE IN THIS PROGRAM Under the guidance of Mr. Monetathchi Jr, the program used an approach of freely sharing and giving to address TIM’s sharing and teaching as a philosophy of living, and that the approach to health and healing is truly a holistic process (Monetathchi 1988a, 1988b). The foundation for his partnership as a medicine man and program director with the nursing team was simple: the nurses had sought his wisdom and asked for his help.The intent of the partnerships and education was not to ‘learn Indian healing ceremonies,’ but rather to share the philosophy of TIM in a way that all people, including patients and healthcare professionals, could choose directions to enhance their own way of living (Monetathchi 1988b). Among the foundational keys provided by the Comanche medicine man were the Seven Sacred Aspects of Life and the essence of a holistic individual (Monetathchi 1987a).These two concepts were shared to establish a basis for the discussion which paralleled some basic tenets of the Culture Care Theory.The Seven Sacred Aspects were shared in the conferences as the values with which nurses, all healthcare providers, or any other individual could guide their daily lives and actions.The seven values offered were: (1)
Volume 28, Issue 1–2, April 2008
CN
67
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 68
Ann O Hubbert
Respect; (2) Honesty; (3) Truth; (4) Humility; (5) Compassion; (6) Wisdom; and (7) Unconditional love. The TIM portrayal of a holistic individual as shared included the concept that ‘Health Equals Balance’ (Monetathchi 1988b, 1988c; Monetathchi, Ortega & Flores 1987). The individual represents balance among and between their physical being, mental being, spiritual being, their environment, and their relationship with God. Illness or disease (dis-ease) was shared as ‘any of those components being out of balance’ (Monetathchi 1988b). In addition, the Circle of Life or Way of the Circle was shared as a guide to the Indian way of being to achieve harmony and balance among all aspects of life, which are all connected, and thus find harmony within the healing process (Garrett & Garrett 1996; Monetathchi 1987b).
CULTURE CARE THEORY A discussion of the theory of Culture Care Diversity and Universality (Culture Care Theory) is offered to show how the theory can be applied as a framework for these partnership experiences among the multiple cultures involved, emphasising the relationships among and between them. Since the 1950s, Madeleine Leininger has been the global leader and developer of the theory of Culture Care Diversity and Universality (Leininger 1988, 1991, 2002d, 2006). The theory’s foundation is used as the framework for discovering relationships that guide working among and between diverse cultures, and specifically to examine the identified program’s approach to spirituality and the healing process among and between cultures. In addition, the Sunrise Enabler provides an indepth view of the dimensions of the theory and the application of the theory to the actions that occurred (Leininger 1991, 2002b: 80–83).The Sunrise Enabler also is a paradigm that supplements the ‘circle if life’ ways of living for many American Indians (Tom-Orme 2002). Leininger (1991) conceptualised generic care as 68
CN
Volume 28, Issue 1–2, April 2008
the cultures’ folk or Indigenous practices, beliefs and values. Culturally congruent care refers to culturally based care used to provide sensitive, creative, and meaningful nursing care to support the client’s general values, beliefs, and lifeways for effective and enriched healthcare, or to deal with illness, disability, or death (Leininger, 2002c: 117–118). The greatest challenges for nurses and all healthcare providers are the understanding and acknowledgement of culturally based care actions in order to provide meaningful [professional] care (Leininger 1991: 47).
Universal care constructs and care values Transcultural nurses have actively used the ethnonursing research process to discover dominant care constructs to be used as guides for nursing and healthcare. Universal care-specific constructs have been identified that are valued by virtually all cultures (Leininger 1991, 2002b: 219–223; McFarland 2002: 107).The first universal construct is respect, and followed by other prominent constructs which include: concern for/about; attention to; helping/assisting acts; listening; presence; being connected; filial love; and understanding. Transcultural research specific to American Indians identified the dominant care constructs as respect; presence; among familiar kin; silence; singing special songs; humour; and, spiritual connectedness (Tom-Orme 2002). All levels of this transcultural research study provide supports for the seven sacred aspects of TIM which emphasized respect as the foremost aspect of behavior valued by American Indians for nurses and healthcare providers to demonstrate throughout their actions and decisions (Monetathchi 1987a). Transcultural nursing research also provides knowledge of the context of culture care values, or the values that give meaning, order, and direction to actions, decisions and lifeways within cultures (Leininger, 1991). It is important for nurses and healthcare providers to understand some general American Indian care
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 69
A partnership of practitioners values. Individual nations or tribes may have specific values, but these general values are offered for basic understanding (Leininger 1991: 357): 1. Harmony between land, people, and all of the environment; 2. Reciprocity with ‘Mother Earth and Father Sky’; 3. Spiritual inspiration/guidance; 4. Traditional Indian medicine; 5. Cultural rituals and ceremonies; 6. Rhythmicity of life with nature; 7. Authority of elders; 8. Pride in cultural heritage and ‘Nations’, and; 9. Respect for and value of children. These values are demonstrated through or are found in the following behaviors: (1) active listening; (2) periods of silence to hear spiritual guidance; (3) rhythmic timing of physical care with nature; (4) respect for medicine people; (5) preserving cultural rituals; and, (6) respectful behaviors.
Sunrise enabler The Sunrise Enabler (Leininger 1991, 2002d: 79–83; Leininger & McFarland 2006: 24–26) provides a crucial guide for nurses to bring the theory into action, and to reflect on their decisions and actions.These three ‘care modes’ can be incorporated by nurses as guides when working between and among cultures: 1. Culture care preservation and-or maintenance: Identify the cultures involved (client, nursing etc), then what client or staff care assistance is wanted? 2. Culture care accommodation and-or negotiation: What care beliefs or practices need to be accommodated, or what needs to be negotiated with staff, clients, etc.? 3. Culture care restructuring and-or repatterning: What practices need to be restructured or repatterned, and by whom?
CN
APPLICATION OF THE THREE CARE MODES TO THE TIM PROGRAM The three action and decision care modes of the Culture Care Theory are described using an indepth actual event in order to offer further discussion of the strongly similar parallel foundations between TIM and the Culture Care Theory. The example demonstrates how this program was able to apply the blended practices of the ‘partnership cultures’ to enhance spirituality and the healing process by expanding the provision of culturally congruent care within the healthcare system. A nurse on an inpatient unit presented the following cultural challenge for discussion during the educational presentations by the traditional medicine people; note that the presenters’ responses were parallel to the Sunrise Enabler. Subsequently, this scenario has been frequently used as a teaching supplement for the Culture Care Theory and the Sunrise Enabler (Hubbert 2004): Mary, a 54 year-old woman from the Southwestern Tohono O’odham Reservation, has been admitted for the first time in her life to a hospital for newly diagnosed acute diabetes. She speaks minimal English, but the nursing staff is pleased that she appears to understand their instructions so well, as she nods frequently, smiles, and asks no questions. The first evening Mary was accompanied for several hours by a granddaughter, but she had to leave to care for her family that lived over two hours away from the hospital. The next morning, Mary smiled and nodded to Kevin, the RN who brought her medications and told her about her new medication regime. However, she refused to take the medications out of his hand. She kept telling him ‘No, I cannot do this ... I need to say my prayers.’ Kevin did not understand, and told her that he would return in 15 minutes, then left her alone to pray. Later, when he returned to her room, she gave him the same response.What
Volume 28, Issue 1–2, April 2008
CN
69
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 70
Ann O Hubbert
is happening between these cultures? The learning and teaching along with the Culture Care Theory which emphasises universal care nurse relayed that he ‘wants to help her.’ constructs through the three care modes of The medicine people’s responses the nurse’s action and decision as depicted in the Sunrise scenario focused first on respect (Monetatchi, Enabler. Respect is the foundation for all of the Ortega & Flores 1987); they facilitated the relationships. Knowledge of the American Indiprogram participants to identify which people an cultural values and the transcultural nursing and issues needed respect, and to identify how Universal Care Constructs would assist the respect may or may not have been demonstrated nurse in making decisions and guide nursing by the nurse’s actions. Participants were guided care actions. The use of the Sunrise Enabler offered into consider the cultural way of living for the Indian, which included: the rhythm of nature and depth care applications through the use of Care her life actions; greeting the new day with prayers; Mode 1, culture care preservation and/or mainspiritual guidance for the new way of living; being tenance.This included respect and preservation for ‘out of balance’ (which included disruption of both cultures: the client’s traditional Indian ways, traditional spiritual practices); and the barriers and the nursing culture’s philosophies and practices and challenges of the hospital environment. The (to the best extent possible). Mode 2, culture care accommodation and-or nurses were asked to consider that possibly a smile and nod from an Indian client did not nec- negotiation in this situation included short essarily indicate that their own expectations range accommodations which later led to long ways were being regarded ‘best’ nor would they range actions for developed with Mode 3. be followed. Rather, the participants were asked Immediate accommodations for Mary included: to consider that instead of having their fast transfer to a room with a bed that faced the East speaking words being understood, acknowl- for her morning prayers; time for her to pray edged, and followed, is was possible they (as with the medications she would take throughout persons) were being greeted and honored for each day; presence of a nurse with she and her their position of authority, and that their dir- family; a tape recorder to play Indian music; ections would be considered when the ‘time space near her bedside for prayer objects with a was right?’ Instead of the nurse leaving for a posted message to staff requesting them to not period of time to provide privacy to pray, there touch the objects; and, the welcoming of a medwere other considerations that needed to be icine person to meet with her in private. It was addressed. What environment was considered also important that these client-focused accomappropriate for the client’s prayers? Her way to modations occur very quickly in order to also pray was to face the sun rising in the East every accommodate the nursing culture’s policies morning, and her room faced westward. Her about care of diabetic client-patients and the new medication had not been ‘blessed’ and she timing of their diabetic medications. Mode 3, culture care restructuring and/or had not been ‘prayed over’ by the medicine person in order to begin this new way of living (in repatterning by the nursing staff/healthcare syshospital) so that she could be ‘in harmony’ tem to meet the needs of the Indian culture rather than being ‘out of balance.’ Further, her included: planning/arranging for Indian clients’ family was not aware of these new changes and bed assignments in the hospital for preferred she would not consider following the nurse’s East rooms; instituting two full-time Indian translator/advocacy positions; a new healthcare directions without their support. This example of American Indian care values system policy welcoming any medicine person can continue to be used for various aspects of at any time with provision for staff escorts 70
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 71
A partnership of practitioners through the hospital; and initiation of numerous language accommodations including audio tapes for client orientation to the hospital room, equipment operation, pain assessment scales, common questions etc. Further culture care restructuring and/or repatterning by the nursing and healthcare system cultures included: nurses’ and any employees’ attendance at TIM workshops to expand their knowledge of culturally specific care; revision of the mission, objectives, and numerous policies of the nursing department to reflect their enhanced cultural values; creation of a new position for an Indian professional nurse case manager; and exchange of educational information with the tribal health council about the experiences within the healthcare system that were unclear. In addition, the TIM program director was hired as a full-time TIM specialist when he retired from IHS. He was provided an office suite and was afforded open access to all areas of the hospital as well as to any client/ patient/family or employees who requested his services. His was frequently requested for interdisciplinary consultations with other healthcare professionals.
CONCLUSION A historical discussion has been given from the experiences of one individual, Catholic faith-based healthcare system with an in-house Traditional Indian Medicine program of care. The program as developed later evolved into a unique array of cultural partnerships and spiritual enhancements for individuals and culture groups. The theory of Culture Care Diversity and Universality (Culture Care Theory) was applied in this discussion as a framework for these endeavors emphasising the relationships among and between the cultures of TIM (traditional Indian medicine people), Southwestern American Indian clients/patients, nursing, other healthcare providers, and the Catholic faithbased healthcare system. Instead of focusing on the differences, the similarities among and
CN
between these varied cultures were discovered and celebrated in this program, thereby benefiting over 7000 people. Although this unique program cannot be replicated identically, opportunities do exist for future cultural partnerships for the enhancement of ‘spirituality and healing in today’s health system’ within the framework of the Culture Care Theory, including creative and reflective applications of the Sunrise Enabler.There is inspiration in this discussion for all nurses, notably the example of one Apache nurse who acted as an advocate for enhanced culturally congruent care, and thereby was able to initiate significant transcultural change not only throughout one healthcare system, but globally.
References
Carondelet Health Services (1986) St. Mary’s Hospital (SMH) Traditional Indian Medicine program wins highest honor, The Weekly Connection, 16 June 1986, CHS Media,Tucson, Arizona. Carondelet Health Network (2008) The Carondelet Health Network Philosophy, Mission, and Values, accessed at http://www.carondelet.org/about /mission.aspx, 6 February 2008. Gardenswartz L and Rowe A (1998) Managing Diversity in Health Care, Jossey-Bass, San Francisco, CA. Garrett JT and Garrett M (1996) Medicine of the Cherokee The Way of Right Relationship, Bear & Company Publishing, Santa Fe, New Mexico. Goold S (2001) Transcultural nursing: Can we meet the challenge of caring for the Australian Indigenous person? Journal of Transcultural Nursing 12: 94–99. Gropper R (1996) Culture and the Clinical Encounter, Intercultural Press,Yarmouth, Maine. Hubbert AO (2004) The Incorporation of Culture Care To Enhance Spirituality in Health Care and Healing. Conference Proceedings, National Association of Catholic Nurses, August, 2004, Santa Fe, New Mexico. Indian Health Service (2007) Provider Services Rendered Codes, PFCE Process Manual (The Blue Book) Supplemental Section, accessed at www.ihs .gov/NonMedicalPrograms/HealthEd/PDF/Blue _Manual_Supp_Sec_PROV_SERVICES_CODES. PDF, on 21 June 2007. Leininger M (1988) Leininger’s theory of nursing: Culture care diversity and universality, Nursing Science Quarterly 2: 152–160.
Volume 28, Issue 1–2, April 2008
CN
71
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 72
Ann O Hubbert
Leininger M (1991) Becoming aware of types of health practitioners and cultural imposition, Journal of Transcultural Nursing 2: 32–39. Leininger M (1994) Transcultural nursing education: A worldwide imperative, Nursing and Health Care 6: 40–51. Leininger M (1997) Transcultural nursing research to transform nursing education and practice: 40 years, Image: Journal of Nursing Scholarship 29: 341–347. Leininger M (2002a). Part I:Toward Integrative Generic and Professional Health Care, in Leininger MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 145–156, McGraw-Hill, New York. Leininger M (2002b) Essential transcultural nursing care concepts, principles, examples, and policy statements, in Leininger MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 45–70, McGrawHill, New York. Leininger M (2002c) Culture care assessments for congruent competency practices, in Leininger, MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 117–143, McGraw-Hill, New York. Leininger M (2002d) Part I:The theory of culture care and the ethnonursing research method, in Leininger MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 71–98, McGraw-Hill, New York. Leininger M (2006) Culture care diversity and universality theory and evolution of the ethnonursing method, in Leininger MM and McFarland MR (Eds) Culture Care Diversity and Universality: A Worldwide Nursing Theory, 2nd edn, pp 1–42, Jones and Bartlett, Sudbury, MA. McFarland MR (2002) Part II: Selected research findings from the culture care theory, in Leininger MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 99–116, McGraw-Hill, New York. Monetathchi E Jr (1987a) The Seven Sacred Aspects: Conference proceedings. A conference sponsored by Carondelet St Mary’s, June 1987,Tucson, Arizona. Monetathchi E Jr (1987b) Resurgence of The Ancient Ways: Conference proceedings. A conference sponsored by Carondelet St Mary’s, March 1988, Tucson, Arizona. Monetathchi E Jr (1988a) The Spirit Within: Confer-
72
CN
Volume 28, Issue 1–2, April 2008
ence proceedings. A conference sponsored by Carondelet St Mary’s, March 1988,Tucson, Arizona. Monetathchi E Jr (1988b) Traditional Indian Medicine: Philosophy of Wholeness, Wellness, and Healing: Conference proceedings. A conference sponsored by Carondelet St Mary’s, March 1988, Tucson, Arizona. Monetathchi E Jr (1988c) Traditional Indian Medicine: Mine,Yours, or Ours: Conference proceedings. A conference sponsored by Carondelet St Mary’s, March 1988,Tucson, Arizona. Monetathchi E Jr (1990) Spiritual Journey: Conference proceedings. A conference sponsored by Carondelet St Mary’s, May 1990,Tucson, Arizona. Monetathchi E Jr, Ortega AP and Flores A (1987) Traditional Indian Medicine: A General Session: Conference proceedings. A conference sponsored by Carondelet St Mary’s, November 1987,Tucson, Arizona. Ortega AP (1989) Traditional Indian Medicine: Conference proceedings. A conference sponsored by Carondelet St Mary’s, August 1989,Tucson, Arizona. Struthers R, Lauderdale J, Nichols L and Strickland CJ (2005) Respecting tribal traditions in research and publications:Voices of five Native American nurse scholars, Journal of Transcultural Nursing 16: 193–201. Tom-Orme L (2002) Transcultural nursing and health among Native American peoples in Leininger MM and McFarland MR (Eds) Transcultural Nursing Concepts,Theories, Research, & Practice, 3rd edn, pp 429–440, McGraw-Hill, New York. United States Bureau of the Census (2000a),Table 1a: Projected Population of the United States, by Race and Hispanic Origin: 2000 to 2050, accessed at www.census.gov/ipc/www/usinterimproj/ natprojtab01a.pdf on 13 May 2007. United States Bureau of the Census (2000b) We The People: America Indian and Alaska Natives in the United States, accessed at www.census.gov/prod /2006pubs/censr-28.pdf on 6 February 2008. United States Department of Health & Human Services (2001) Closing the Gap: Revised CLAS Standards, Office of Minority Health Newsletter, p 3. Weaver HN (1999) Transcultural nursing with Native Americans: Critical knowledge, skills, and attitudes, Journal of Transcultural Nursing 10: 197–202.
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 73
* * * * N O W AVA I L A B L E * * * * A DVANCES
IN
C ONTEMPORARY
I NDIGENOUS H EALTH C ARE Australian, New Zealand and North American Perspectives Edited by Eileen Willis, Vicki Smye and Maria Rameka Dedicated to Irihapeti Merenia Ramsden ISBN 0-9750436-9-2; xiii + 203 pages; softcover; September 2006 A special issue of Contemporary Nurse, Volume 22, Issue 2 Preliminaries Dedication: Irihapeti Merenia Ramsden — Vicki Smye Vale: Nancy de Vries RN (Auntie Nance) — John Daly, Debra Jackson Vale: Nancy de Vries RN (Auntie Nance) — Jill Iliffe Foreword: The Practice and Politics of Indigenous Health Nursing — Denise Wilson Introduction • Indigenous Health Care: Advances in nursing practice — Vicki Smye, Maria Rameka, Eileen Willis • Critical Cultural Perspectives and Health Care Involving Aboriginal Peoples — Annette J Browne, Colleen Varcoe • Issues of Language Across the Cultural [and colonial] Divide — Eileen Willis, Maria Rameka, Vicki Smye Nursing in the Indigenous Context • Opinion Piece: ‘It’s only a mistake if you make it twice’ — Kim O’Donnell • Decolonisation: A critical step for improving Aboriginal health — Tania Edwards, Juanita Sherwood • Amorphous Practice: Nursing in a remote Indigenous community of Australia — Jennifer Helen Cramer • Characterising Maori Nursing Practice — Victoria Simon Indigenous Understandings of Mental and Physical Health • Opinion Piece: Indigenous Values, Cultural Safety and Improving Health Care: The case of Native Hawaiians — Laurie D McCubbin • Assessing Pain Across the Cultural Gap: Central Australian Indigenous peoples’ pain assessment — Claire Fenwick
• At What Cost to Health? Tlicho women’s medical travel for childbirth — Pertice M Moffitt, Ardene Robbinson Vollman • Insights on Aboriginal Peoples’ Views of Cancer in Australia — Pam McGrath, Hamish Holewa, Katherine Ogilvie, Robert Rayner, Mary Anne Patton • The Experience of Whanau Caring for Members Disabled from the Effects of a Cerebro-Vascular Accident — Andrea Corbett, Karin Francis, Ysanne Chapman Nursing Partnerships in Indigenous Health • Opinion Piece: Nursing Partnerships in Indigenous Health — Tzu-I Tsai • Relationship Building for Research: The Southern Saskatchewan/Urban Aboriginal Health Coalition — Sandra Bassendowski, Pammla Petrucka, Marlene Smadu, Chief Roger Redman, Carrie Bourassa • A Nursing Partnership for Better Outcomes in Aboriginal Mental Health, Including Substance Use — Charlotte de Crespigny, Inge Kowanko, Scott Wilson, Helen Murray, Jackie Ah Kit, David Mills • Meeting the Health Needs of Indigenous People: How is nursing education meeting the challenge? — Sally Goold, Kim Usher • The Yapunyah Project: Embedding Aboriginal and Torres Strait Islander perspectives in the nursing curriculum — Robyn Nash, Beryl Meiklejohn, Sandy Sacre • Is it Aboriginal Friendly? Searching for ways of working in research and practice that support Aboriginal women — Janet Kelly Epilogue: Nursing, Indigenous Peoples and Cultural Safety: So what? Now what? — Madeleine Dion Stout, Bernice Downey Book Reviews
Course Coordinators are invited to contact the Publisher for an adoption evaluation copy. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
e C ontent
PTY
management LTD
Volume 28, Issue 1–2, April 2008
CN
73
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 74
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 74–82.
Lebanese cancer patients: Communication and truth-telling preferences ABSTRACT
Key Words nursing; communication; phenomenology; qualitative study; truth telling
The purpose of this study was to describe and interpret the phenomenon of communication as lived by Lebanese cancer patients. Phenomenology based on the Utrecht School was chosen as an interpretive descriptive methodology to guide the processes of data collection, analysis and synthesis. In-depth semi structured interviews were carried out with a purposeful sample of ten cancer patients. Results of this qualitative study emphasise the needs of Lebanese cancer patients for a clear and truthful communication with healthcare professionals, and family members. Informants highlighted the influence of words used during communication on their outlook and morale.They also stressed the need to move from the paternalistic approach in care provision to patient-centered care that promotes patient autonomy. Informants clearly accentuated their rights to be told the truth about their condition. Received 6 July 2007
MYRNA ABI ABDALLAH DOUMIT Assistant Professor School of Nursing American University of Beirut Beirut, Lebanon
INTRODUCTION
E
ffective communication between health professionals and people with cancer is an international aim, as evidenced in published literature (Fallowfield & Jenkins 1999; Gysels, Richardson & Higginson 2004). It has long been documented and accepted that effective communication with cancer patients is a significantly essential element in any efficient care process 74
CN
Volume 28, Issue 1–2, April 2008
Accepted 25 March 2008
CN HUDA HUIJER ABU-SAAD Professor of Nursing Science Director, School of Nursing American University of Beirut Beirut, Lebanon
(Hurney 2000;Thorne, Bultz & Baile 2005). In fact communication skills are a key to achieving important goals of the clinical encounter in oncology (Baile & Aaron 2005). Good information exchange can decrease psychological distress, promote better levels of adherence, and introduce realistic expectations (Mills & Sullivan 1999). Empirical evidence has revealed that supportive communication can positively affect
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 75
Lebanese cancer patients: Communication and truth-telling preferences patients’ psychological adjustment and quality of life. Consequently, the value of effective communication skills is stressed in cancer care (Liu, Mok & Wong 2005; Maguire 1999). Regardless of the value of communication to both patients and providers, researchers have reported that only 57% of patients are satisfied with their providers’ listening skills, explanations, and respect for their opinions (US Department of Health and Human Services 2003). Further studies reported that patients are often unhappy with the amount and nature of information they receive (Parker et al 2001; Veronesi et al 1999).The issue of how and how much to tell patients with cancer about their diagnosis and prognosis is still approached differently in different countries (Fujimori et al 2007; Georgaki et al 2002). In Lebanon, cancer is one of the leading causes of death (Daher et al 2002). It is believed to be a protracted illness causing great disability and suffering that finally leads to a painful death. Cancer is therefore not a preferred word to use, and euphemisms, such as waram (as pronounced in Arabic) which means ‘growth’ or ‘lump’ have been developed as alternatives. Regarding the provision of information about cancer in Lebanon, in general the primary family caregiver is usually informed by the physician of the patient’s diagnosis and prognosis before the patient is told the truth. Then the family caregiver decides whether the patient should be told the truth, usually after discussion with other family members and the physician frequently accepts the family’s decision. In a study assessing knowledge, attitudes and practices of physicians and nurses regarding palliative care in Lebanon, Abu-Saad Huijer and Dimassi (2007) reported that only 19.1% of physicians inform the patients about their diagnosis. Lebanese physicians prefer informing and involving the family more than the patient. In Lebanon, it is important to note that information about cancer patients’ desire for communication and truth telling from a patient’s perspective is
CN
unavailable. This article is intended to contribute to the literature by providing descriptive and interpretive data about the phenomenon of communication from the perspective of Lebanese patients suffering from cancer.
Purpose of the study Our reflections on the phenomenon of communication surfaced while conducting a qualitative study about the lived experience of Lebanese oncology patients receiving palliative care.The Need to Communicate emerged from the participants’ interviews as an important element in their lives. All participants highlighted communication as an important factor for morale boosting or as a demoralising factor depending on the communication process followed and the words used by others. So, further analysis was carried out to highlight the theme of communication within the Lebanese culture, which is the subject of this article. Research methods
Design Phenomenology based on the Utrecht school was chosen as an interpretive descriptive methodology to guide the processes of data collection, analysis and synthesis, from which we generated findings in relation to various patterns and themes across the sample (Polit & Beck 2008). Phenomenology, specifically the Utrecht approach, is the best fit for this study because it describes the meaning of the lived experience through the shared essences among participants, and it uses the language to interpret the connotations of the experience of the participants. Thus, a comprehensive, culturally meaningful competent understanding of the phenomenon will be provided.This approach is most valuable when the activity at hand is to comprehend an experience as it is identified by those who are living it and to respond to questions of meaning (Polit & Beck 2008; Speziale & Carpenter 2003).
Volume 28, Issue 1–2, April 2008
CN
75
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 76
Myrna Abi Abdallah Doumit and Huda Huijer Abu-Saad
Selection of informants
Setting
Purposive sampling was employed. Informants were recruited based on the following inclusion criteria: 1. Lebanese speaking Arabic; 2. Living in Lebanon; 3. Age of 18 years or above; 4. Confirmed diagnosis of any type of cancer; 5. Low expectations for remission or cure as reported by the informant’s oncologist; 6. Receiving palliative care based on the informant’s physician confirmation; 7. Informant’s knowledge of his or her palliative condition; 8. Agreement to share personal experiences and participate in the study; 9. Agreement to be interviewed without the presence of a third person in order to guarantee freedom for the informant to communicate his or her feelings; 10. Informant’s ability of signing his or her name on the consent form.
Interviews took place based on the informants’ discretion regarding place and time. Eight interviews took place at the informants’ homes and two in a hospital setting. Informants were residents of both rural and urban areas of Lebanon but receiving care in Metropolitan Beirut.
Recruitment At first the principal investigator discussed the study with community intermediaries (nurses, house wives) and oncologists. As the community intermediaries and the oncologists identified possible informants, the PI was introduced to the potential informant and offered an invitation to contribute in the study. Informants enrolled through community intermediaries were told that their treating physician will be notified of their involvement in the study.
Description of informants Informants represented a variation with regard to major variables such as tumor site, patient demographics characteristics, and treatment modalities. The sample comprised six women and four men.They ranged in age from 21 to 71 years with varied socioeconomic and educational backgrounds and a diversity of tumor sites and treatments. 76
CN
Volume 28, Issue 1–2, April 2008
Data collection Data collection took place during summer of 2005. In-depth semi structured interviews were conducted privately between the PI researcher and informant. All informants were interviewed twice.The reason for the second interview was to confirm with the informant the preliminary analysis and to clarify previous statements in the first interview. Interviews were conducted in Arabic and then translated to English and back translated to Arabic to ensure credibility of the translated data.Translation was done by a bilingual trained translator.The duration of the first interview varied between 50 to 60 minutes; while the length of the second interview ranged between 30 and 45 minutes. All interviews were audio taped and transcribed verbatim, with digital text entered into NVivo 1.2 software for sorting and organising of raw data. Informants were guaranteed confidentiality and pseudonyms were used. The first set of interviews was triggered by the following grand tour question ‘Can you tell me about how you have experienced your illness?’ In addition probing technique was used for explanatory accounts of participants’ experience such as ‘Please tell more about it’, ‘Is it possible to give an example?’ In each interview, the informant was the main narrator and the PI researcher was mainly a listener and a facilitator (Speziale and Carpenter 2003).
Data analysis Analysis of data was ongoing throughout data collection, transcription, and repeated readings of the text. Analysis was done based on the Utrecht School of Phenomenology. Data were
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 77
Lebanese cancer patients: Communication and truth-telling preferences examined systematically using a system of coding to identify particular phenomena and categories of interest. Analysis was done independently by two researchers in the study team, who then compared and discussed the results of their work for similarities and differences. The same codes were kept, similar codes were combined, and the revised codes were discussed and changed until concordance was achieved. Results of the study represent the first documented data about the lived experience of Lebanese cancer patients (Doumit, Abu-Saad Huijer & Kelley 2007). For the purpose of this study analysis, we draw excerpts derived from the participants’ description to reflect on the implications of the tacit assumptions that Lebanese healthcare professionals hold in relation to cancer and communication.
Rigour of the study
CN
control, disease reminder, and burden on others; 2. Dislike for pity: threat to self-perception; 3. Worried about the family and the family’s worry; 4. Reliance on God and divinity; 5. Dislike of the hospital stay: feeling trapped in time, place, and disease; 6. Dislike of being non-productive; 7. Fear of pain and suffering; 8. The need to communicate. It is worth noting that these core themes were not identified or listed in order of importance (Doumit et al 2007). Further analysis was carried out to highlight the themes on communication which are the subject of this article. The findings on communication that emerged from the data consisted of two themes and sub-themes: 1) the need to communicate: participant–family communication, participant– physician communication, and type of words or messages used or sent and 2) worried about the families and the family’s worry. In this theme the idea of cancer patients not sharing or communicating their worries with family members prevailed.
Steps recommended by Lincolin and Guba (1985) were followed to secure rigor of study method. Credibility was fulfilled by within method triangulation for data collection, member check and peer debriefing. Transferability was secured by the use of thick descriptions from the interviews. Dependability and confirmability were guaranteed by doing intercoder reliability as suggested by Polit and Beck (2008) Need to communicate and Marques and McCall (2005). All informants without exception highlighted the importance of communication in their disease trajectory. Informant–family communicaEthics Approvals from Institutional Review Boards tion and truth telling were reported as major were secured before initiating data collection. stressors. Houda, a 51-year-old woman with All informants were provided with information breast cancer and metastasis to bone expressed sheet describing the study and were asked to her annoyance with her family because they hid give written consent to interviews and audio the truth from her. She said: ‘I prefer the truth from the beginning. I am not a child.’ recording. Ghandi a 59-year-old man with colon cancer and metastasis to the bone, said: RESEARCH FINDINGS Eight core themes emerged from this study, There is lots of openness between my wife, which reveal the lived experience of Lebanese my son and me. We talk about my condicancer patients receiving palliative care. The tion… It helps a lot. It strengthens the emerging themes were as follows: morale and it makes me forget my disease… 1. Distressed from being dependent: loss of
Volume 28, Issue 1–2, April 2008
CN
77
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 78
Myrna Abi Abdallah Doumit and Huda Huijer Abu-Saad
Informant–physician communication was also emphasised as an important aspect of the communication process. Aniss, a 55-year-old man with colon cancer and metastasis to lung, bone, and brain described the relationship that should exist between the treating physician and the patients and said: ‘The physician should understand his patient. If the patient is ready to understand the truth, then he should talk to him. I prefer the truth.’ He added: ‘Nurses and physicians have to come and talk with the patient, your psychology will be relaxed.’ Samer, a 21-year-old male with colon cancer and bone metastasis said: A good day is when my sister finally told me that I have cancer, why? Because I felt it in my heart. I felt that they were hiding something from me.
metastasis to lung, brain and bone. At the time of the interview Hind was still upset from a conversation that she had two days prior to the interview with her brother-in-law and his wife. Though Hind perceived them as her support system and she highlighted their caring attitudes towards her, one remark from them regarding her condition made her feel upset. She said: It hurt me because as a person who is 60 years old and receiving treatment, psychologically you feel wounded. You are under treatment and this might mean the end, this is what it means to you. He is not the first one. Maybe they are 15 for now who said, ‘We were not born to stay.’ Maybe they do not mean it, but psychologically you feel wounded. He is not the only one that is talking like this, but around 20 individuals said so far,‘Do not worry.We were not born to stay.’
Amine narrated a story to emphasise the importance of tactful communication and the choice The impact of communication on Hind was not always positive. Relatives, with their approach, of words in communicating and he said: made her feel frustrated because they reminded One day there was a king. One day a man her of her unstable health status. came to him and he told him you are going to bury all your parents, so the king ordered his death.Then another man came to him and he Worried about the families told him you are going to survive all your and the family’s worry parents, so he gave him lots of money. So the In this second theme, informants shared their minister questioned his king. Sir, what did the worries about their family members. They first man tell you to order his death? And the clearly stated that they opted to hide their sufking told him. Then he asked what did the ferings and pain from their children or beloved second man tell you? And the king answered. ones because they did not want them to worry So the minister asked him, ‘My king, what’s about them. Informants were protecting their the difference between the two men?’ The family members by not sharing or communicatking told him the results are the same, but ing with them their worries, ideas and feelings the way it was said made the difference. So a regarding cancer or death. Sonia, a 65-year-old woman with breast canword can make the difference and this is how cer and metastasis to bone, lungs, liver, uterus my physician deals with me. He tells me and brain said: things bit by bit. This is important because I do not like rough words. I like the way he I wish I was able to hide it (the disease) even deals with me. He is very sensitive with me. from my family members. I do not want The choice of words with cancer patients can them (children) to feel afraid or worry that I impact on their morale as mentioned by Hind, a am sick. I do not show anything, I do not 65-year-old woman with breast cancer and show anything. 78
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 79
Lebanese cancer patients: Communication and truth-telling preferences
CN
Similarly, Houda shared her worry about her society regarding the impact of knowing or dischildren’s worry about her and expressed her cussing the diagnosis of cancer on patients’ morale expressed the need to communicate, wishes of hiding the truth. She said: and highlighted their right to truth telling.They I do not want them (her children) to worry clearly mentioned that communication with the about me, they are still young. They think physician and family members was seen as a Mama will die. I do not like it. I wish they mean for relieving their stress.These statements did not know about my condition.This is my coming from informants living in a culture which favors paternalism over individualism are nature. quite significant. However one needs to be cautious because due to the limited number of DISCUSSION Social attitudes towards cancer and the societal informants in the study, there maybe some prevailing norms regarding communication and Lebanese cancer patients who still would prefer truth telling are all known to be profoundly the traditional approach of non disclosure. affected by cultural beliefs and norms (Mystaki- Therefore, patients need to be asked what they dou et al 2004). In Lebanon, most of the times want to know about their illness before the prothe patient’s family is informed about the diag- vision of information is provided or a cultural nosis of cancer before it has been discussed with decision is made to non-disclose. It is worth the patient. Family members keep the diagnosis noting that an important part of communication and prognosis a secret in order to protect the is being aware to the amount and type of inpatient from emotional trauma.The attitude of formation the patient requests, knowing that many healthcare professionals and their ap- patients may want different types and amount of proach to communication and truth telling in information as their illnesses progress (Clayton cancer cases mirrors that of family members 2006). Consequently communicating with (Abu-Saad Huijer & Dimassi 2007; Hamadeh & patients on an individual basis is highly recomAdib 1998). It is worth noting that there was a mended (Fujimori et al 2007). Informants of this study stressed the need to perception among Lebanese healthcare professionals that Lebanese cancer patients are not know about their diagnosis and prognosis, yet, ready or willing to discuss their condition or they clearly mentioned their preferences for even to participate in a qualitative study.The fear hiding their sufferings and pain in order not to was also that family members may constitute a disturb their beloved ones. Findings in the literbarrier preventing patients from participating in ature (Goldsteen et al 2006; Helseth & Ulfsaet an unattended, in depth interview (Adib & 2005;Wheeler 2005) emphasise the importance Hamadeh 1999). But contrary to the above, all of communication to cancer patients yet they informants without exception expressed grati- highlight the patients’ preferences for hiding tude to the researchers because they gave them their sufferings from their beloved ones. Informants of this study wanted the commuthe opportunity to discuss their condition, worries, and concerns related to their current situa- nication to be tempered with consideration tion. Family members did not object to the regarding the choice of words or ideas used by interview; on the contrary, they were facilitators others. In order to protect their family members from being hurt or disturbed, informants in creating the best environment. This is the first study to describe the views kept their concerns, ideas and fears regarding and needs of Lebanese cancer patients regarding their condition silent. In Lebanon, it is worth communication. Informants of this study, in noting that in general family members prefer contrast to the existing ideas in the Lebanese not to discuss cancer diagnosis and prognosis
Volume 28, Issue 1–2, April 2008
CN
79
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 80
Myrna Abi Abdallah Doumit and Huda Huijer Abu-Saad
with patients thinking that it is a kind of protection to their feelings. But, evidences from the literature (Lin et al 2003; Mizuno et al 2002) imply that patients’ stress is possible to be superior with ambiguity and doubt around their illness. So, leaving the patient in the shadow does not serve the purpose. Moreover, the families most of the time ask from the medical professional not to reveal the truth about the diagnosis and prognosis of the cancer to the patient. However, all study informants reported that despite efforts of family members of hiding the truth they knew of their diagnosis. Results reported in this study are in line with previous studies conducted on cancer patients (Clark & Volker 2003; Begley & Blackwood 2000; Fujimori et al 2007; Oliffe et al 2007) regarding communication needs in cancer patients and cultural influences. In many Eastern societies there is a tendency for physicians to abide by the families’ decisions and wishes on disclosure or non-disclosure and non-disclosure are more prevalent (Lin et al 2003).The choice of not telling a patient the diagnosis of cancer has many roots. One reason being the culture and cultural expectations of a specific society. In the Eastern cultures family is very important. Harmony and balance with family relationships should supersede personal need and further add to social equilibrium. In Chinese societies there is a cultural conviction that cancer can be acquired by contact with a person with cancer. It is predicted that these values and beliefs would directly affect the choice of patients, families and health professionals to the disclosure or non-disclosure of a diagnosis of cancer (Mizuno, Onishi & Ouishi 2002; Mok & Martinson 2000). In a cross sectional study to assess the knowledge, attitudes and practices of physicians and nurses towards palliative care in Lebanon AbuSaad & Dimassi (2007) reported that the majority of the respondents believe terminally ill patients and their families should be informed of the diagnosis and prognosis. However, it was reported that only 19% of physicians routinely 80
CN
Volume 28, Issue 1–2, April 2008
inform terminally ill patients about their diagnosis.Whereas it is reported that in most Western societies’ disclosure is the expected norm (Baile et al 2002; Georgaki et al 2002). Baile et al (2002) in an international study which compared the practices of oncologists on four continents reported that physicians from Western countries were less likely to deny the patient unfavorable information at the family’s request. Lebanon’s geographical location between the East and the West, and the Western medical and nursing curricula followed at different universities are believed to have an influence on its healthcare culture. The norm was to hide the truth from patients regarding the diagnosis of cancer; however, the trend is changing. Patients, especially young people are becoming more assertive and knowledgeable about health issues. However, the Western culture of communication and truth telling are still in their infancy stages. Hamadeh and Adib (1998) in a study assessing cancer truth disclosure by Lebanese doctors reported that unless hard evidence emerges indicating that Lebanese patients are seeking empowerment and would rather be told the truth, it is less likely that those physicians would change their attitude and reveal the diagnosis.
CONCLUSIONS Results of this qualitative study emphasise the needs of Lebanese cancer patients to have clear and truthful communication with healthcare professionals, and family members. Informants highlighted the influence of words used during communication on their morale. Informants also stressed the need to move from the paternalistic approach to the promotion of autonomy. They clearly accentuated their rights to be told the truth about their condition. Yet, they highlighted the gentle approach to communication versus the blunt style. Consequently, this study represents a change in expectations and certainly of the existing norms within the Lebanese culture regarding communication and truth telling. Also, it provides preliminary evi-
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 81
Lebanese cancer patients: Communication and truth-telling preferences
CN
exploratory study. Journal of Clinical Oncology dence that the cultural and values which aim at 20: 2189–2196. protecting cancer patients from knowing their diagnosis and prognosis is not in line with the Begley A and Blackwood B (2000) Truth-telling versus hope: A dilemma in practice. Internapatients’ wishes and needs. tional Journal of Nursing Practice 6: 26–31. Clark A and Volker DL (2003) Truthfulness. Limitations Clinical Nurses Specialist 17: 17–18. The qualitative approach followed in this study does not allow for generalisation of findings but Clayton M (2007) Communication: An important part of nursing care. American does provide interesting insights into the conJournal of Nursing 106: 70–75. cept of communication and cancer within the Lebanese culture. It is worth noting, that gener- Daher M,Tabari H, Ammar W, AbouNasr Nabhan T, Bou Khalil T and Dakwar A (2002) alisability is not a goal of phenomenology. The Lebanon: Pain relief and palliative care. experience stays private but its connotation and Journal of Pain and Symptom Management 24: significance become public (Ricoeur 1976). 200–204. Doumit M, Abu-Saad Huijer H and Kelley J Recommendations (2007) The lived experience of Lebanese We do believe that there is much to be learned oncology patients receiving palliative care. about communication and cancer within the European Journal of Oncology Nursing 11: Lebanese culture. So, it is highly recommended 309–319. to expand on the results of this study and conFallowfield L and Jenkins V ( 1999) Effective duct a national study assessing the communicacommunication skills are the key to good tion needs of Lebanese cancer patients. Studying cancer care. European Journal of Cancer 35: the preference for truth telling among Lebanese 1592–1597. nurses and physicians is highly suggested. MoreFujimori M, Akechi T, Morita T, Inagaki M, over, emphasising communication as an imAkisuri N, Sakano Y and Uchitomi Y (2007) portant aspect of cancer care in the Lebanese Preferences of cancer patients regarding the Nursing and Medical curricula emerges as a key disclosure of bad news. Psycho-Oncology 16: element that needs further follow up and study. 573–581. Georgaski S, Kalaidopoulou O, Liarmakopoulos References I and Mystakidou K (2002) Nurses’ attitudes Abu-Saad Huijer H and Dimassi H (2007) towards truthful communication with Palliative care in Lebanon; knowledge, patients with cancer: a Greek study. Cancer attitudes and practices of physicians and Nursing 25: 436–441. nurses. Lebanese Medical Journal 55: 121–128. Adib SM and Hamadeh GN (1999) Attitudes of Goldsteen M, Houtepen R, Proot I, Huijer AbuSaad H, Spreeuwenberg C and Widdershoven the Lebanese public regarding disclosures of (2006) What is a good death? Terminally ill serious illness. Journal of Medical Ethics 25: patients dealing with normative expectations 399–403. around death and dying. Patient Education and Baile W and Aaron J (2005) Patient-physician Counseling 64: 378–386. communication in oncology: past, present, Gysels M, Richardson A and Higginson I (2004) and future. Current Opinion in Oncology 17: Communication training for health 331–335. professionals who care for patients with Baile W, Lenzi R, Parker P, Buckman R and cancer: a systematic review of effectiveness. Cohen L (2002) Oncologists’ attitudes Supportive Care in Cancer 12: 692–700. towards and practice in giving bad news: an
Volume 28, Issue 1–2, April 2008
CN
81
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 82
Myrna Abi Abdallah Doumit and Huda Huijer Abu-Saad
Hamadeh GN and Adib SM (1998) Cancer truth disclosure by Lebanese doctors. Social Science and Medicine 47: 1289–1294. Helseth S and Ulfsæt N (2005) Parenting experiences during cancer. Journal of Advanced Nursing 52: 38–46. Hurney C (2000) Communicating about cancer: patients’ needs and caregivers’ skills. Support Care Cancer 8: 437–438. Lincolin YS and Guba EG (1985) Naturalistic Inquiry. Beverly Hills, CA: Sage Publications. Liu J, Mok E and Wong T (2005) Perceptions of supportive communication in Chinese patients with cancer: experiences and expectations. Journal of Advanced Nursing 52: 262–270. Lin CC,Tsai H, Chiou J, Lai Y, Kao C and Tsou T(2003) Changes in levels of hope after diagnostic disclosure among Taiwanese patients with cancer. Cancer Nursing 26: 155–160. Maguire P (1999) Improving communication with patients with cancer. European journal of Cancer 35: 2058–2065. Marques JF and McCall C (2005) The application of interrater reliability as a solidification instrument in a phenomenological study. The Qualitative Report 10: 439–462. Mizuno M, Onishi C and Ouishi F ( 2002) Truth disclosure of cancer diagnoses and its influence on bereaved Japanese families. Cancer Nursing 25: 396–403. Mills ME and Sullivan K (1999) The importance of information giving for patients newly diagnosed with cancer: A review of the literature. Journal of Clinical Nursing 8: 631–642. Mok E and Martinson I (2000).Empowerment of Chinese patients with cancer through selfhelp groups in Hong Kong. Cancer Nursing 23: 206–213. Mystakidou K, Parpa E,Tsilila E, Katsouda E and Vlahos L (2004) Cancer information disclosure in different culture. Support Cancer Care 12: 147–154.
82
CN
Volume 28, Issue 1–2, April 2008
Oliffe J,Thorne S, Hislope TG and Armstrong EA (2007) Truth telling and cultural assumptions in an era of informed consent. Family Community Health 30: 5–15. Parker PA, Baile WF, De Moor C, Lenzi R, Kudella AP and Cohen L (2001) Breaking bad news about cancer: patients’ preferences for communication. Journal of Clinical Oncology 19: 2049–2056. Polit DF and Beck CT (2008) Nursing Research: generating and assessing evidence for nursing research, 8th edn,Wolters Kluwer & Lippincott Williams & Wilkins, Philadelphia. Ricoeur P (1976) Interpretation theory: Discourse and the surplus of meaning. Fort Worth,Texas: Christian University Press. Speziale HJS and Carpenter DR (2003) Qualitative Research in Nursing, 3rd edn, Philadelphia: Lippincott,Williams & Wilkins. Thorne S, Bultz B and BaileW (2005) What are the costs of poor communication in cancer care? A critical review of the existing empirical evidence. Psycho-oncology 14: 875–884. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion (2003) Communicating health: priorities and strategies for progress.Action plans to achieve the health communication objectives in healthy people 2010, http://odphp.osophs .dhhs.gov/projects/healthcomm. Veronesi U,Von Kleit S, Redmond K,Veronesi S, Costa A, Delvaux N, Freilich G, Glaus A, Hudson T, McVie JG, Macnamara C, Meunier F, Pecorelli S, Serin D and the CAWAC Study Group: A European survey of the perspectives and experiences of women with female cancers. European Journal of Cancer 35: 1667–1675. Wheeler MS (2005) Interviews with patients who have cancer and their family members provide insight for clinicians. Home Healthcare Nurse 23: 642–646.
CNJ 28_1_2_internal.qxd
14/07/2008
12:25 PM
Page 83
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 83–97.
Bridging generic and professional care practices for Muslim patients through use of Leininger’s culture care modes ABSTRACT
Key Words nursing; generic care; professional care; Leininger; culture care modes; Muslim
The purpose of this article is to provide knowledge of traditional Muslim generic (folk) care beliefs, expressions and practices derived from research and descriptive sources, in order to assist nurses and other health care professionals to integrate generic (folk) into professional care practices. Muslim generic (folk) care beliefs and practices related to the caregiving process, health, illness, dietary needs, dress, privacy, modesty, touch, gender relations, eye contact, abortion, contraception, birth, death and bereavement were explored. A discussion involving the use of Leininger’s culture care preservation and/or maintenance, culture care accommodation and/or negotiation and culture care repatterning and/or restructuring action modes to bridge the gap between generic (folk) and professional (etic) care practices and to consequently promote culturally congruent care is presented. Received 22 August 2007
HIBA WEHBE-ALAMAH Assistant Professor Department of Nursing School of Health Professions and Studies The University of Michigan-Flint Flint MI, USA
INTRODUCTION
I
t is well known that we live in a multicultural era characterised by increased globalisation. Nurses all around the world are caring for clients of diverse ethnic backgrounds with different cultural beliefs, needs and practices. According to the American Community Survey, 288 378 137 individuals resided in the United States of America (USA) in 2005. Of these,
Accepted 15 March 2008
CN
74.7% were white, 12.1% were black or African American, 0.8% were native Americans and Alaskan natives, 4.3% were Asians, 0.1% were native Hawaiians and Pacific Islanders and 6% were other races (United States Census Bureau 2005). Similarly, 19 855 288 persons lived in Australia in 2006 including 2.3% Indigenous Aboriginal and Torres Strait Islanders (Australian Bureau of Statistics 2007a). In addition, the 2001 ‘reported ancestry by-self’ table shows that 38.1% of residents in Australia are descendants of Australian, New Zealanders, Maori, Aboriginal and Torres Strait Islander ancestors, 65.8% have European origins such as English, Irish, Italian and German, 18.8% have Asian ancestry namely Chinese, Indian and Vietnamese, and 2% have Middle Eastern roots, specifically Lebanese and Turkish (Australian Bureau of Statistics 2007b).
Volume 28, Issue 1–2, April 2008
CN
83
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:25 PM
Page 84
Hiba Wehbe-Alamah
In the USA and possibly worldwide, nurses and other health care providers are no longer caring for patients of a predominant ancestry, but are caring for clients with diverse cultural values, beliefs and practices.To facilitate culturally congruent care and ethical interactions with patients of diverse cultural backgrounds, nurses and other health care providers must not ignore the importance of culture and must recognise their own culture specific care interpretations, expressions and practices (Zoucha & Husted 2000). Leininger (2002) has long maintained that it is a human right to have one’s cultural values, beliefs, practices and needs respected, understood and appropriately used within any caring or curing context. Such cultural values include generic care beliefs, practices and values held by individuals of diverse cultural backgrounds (Leininger & McFarland 2002). Having recognised the increased use of complementary, alternative, folk and/or generic care practices, Leininger holds that providing culturally congruent care necessitates recognising and bridging the two types of caring that exist in every culture: the generic (emic or folk) and professional (etic) caring systems (Leininger 1995; Leininger & McFarland 2002). Leininger (2002) defined generic care as the learned and transmitted lay, indigenous, traditional, or local folk knowledge and practices aimed at providing assistive, supportive and facilitative actions that improve well-being and help with dying and other human conditions. The theorist referred to professional care as the formal and explicit cognitively learned professional care knowledge and practices that are taught in educational institutions to assist nurses in providing assistive, supportive and facilitative actions to improve the health, prevent illness and help with dying and other human conditions (Leininger 2006). This article seeks to provide knowledge of generic (folk) care beliefs, expressions and practices used by conservative Muslims living in the USA, based on research and descriptive sources, 84
CN
Volume 28, Issue 1–2, April 2008
in order to assist nurses and other health care providers to incorporate generic care practices with professional care practices.This may especially be important when one takes into consideration that Muslims currently comprise about 1.5 billion people or one fifth of the world total population (Mughees 2006). Furthermore, Islam is the second largest religion in the world and has about 15 million followers in Europe, 8 million in the USA, 145 million in Indonesia, 92 million in Pakistan, 50 million in the Soviet Union and 340 392 people in Australia (Mughees 2006; Rashidi & Rajaram 2001). Contrary to popular belief, only 20% of Muslims worldwide are of Arabic origin (Gulam 2003). It is expected that by the year 2010, the Muslim community will be the largest nonChristian community in the USA and will exceed 15 million by the year 2025 (Underwood et al 1998 as cited in Rashidi & Rajaram 2001: 55). In Australia where 33% of Muslims are native born and the others come from 67 different countries, Muslims already account for the largest religious group second to Christians. The roots of Islam in Australia date back to 1650 AD, as a result of interactions between Indigenous Australians with Muslim Indonesian fishermen and again in the 18th and 19th centuries with Afghan Cameleers who helped build the overland telegraph line and the Ghan railway from Port Augusta to Alice Springs (Gulam 2003). While Muslims in the US, Australia and other countries share similarities in their cultural beliefs, expressions and practices, they also have much diversity.The two major sects in Islam are those of Sunni and Shi’a. In 2005, of the 1.5 billion Muslims in the world, 85–90% followed the Sunni branch of Islam, while 10–15% followed the Shi’a branch.The majority of Shi’a Muslims live in Iran, Iraq, Bahrain and Azerbaijan, with large concentrations found in Afghanistan, Lebanon, Kuwait, Pakistan, Saudi Arabia, Syria and Yemen (Armanios 2004). In the United States, 80% of Muslims are Sunnis and tend to
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 85
Bridging generic and professional care practices for Muslim patients be concentrated in New York City, Los Angeles, Chicago, Houston, Boston, Detroit and Toledo (Hodge 2005). Sunni and Shi’a Muslims share many commonalities and differences in their religious and cultural beliefs, expressions and practices. Just like with any cultural group, it is erroneous to assume that all members of the cultural group abide by the same universal values and norms. Acculturation, assimilation and enculturation processes affect the level of adherence to religious and cultural principals. Muslims all around the world range from the very liberal to the extremely fundamentalist. This article focuses on generic (folk) care practices common among conservative and traditional Muslims derived from ethnonursing studies and other descriptive sources. Knowledge of generic (folk) care practices that are common among Muslims is critical to providing culturally congruent care to this group. According to Simpson and Carter (2008), there is a scarcity of literature that addresses culturally appropriate health care practices for Muslim immigrant women in rural areas in the USA. The influx of new Muslim immigrants into the USA, coupled with a lack of knowledge in relation to cultural, religious and healthcare needs of unfamiliar populations, are creating new health care challenges for health care providers. Actual or perceived ignorance in relation to the Islamic cultural or religious beliefs and practices were found to create a barrier and a deterrent to health care access on the part of Muslim women in rural areas (Simpson & Carter 2008). Rajaram & Rashidi (2001) pointed out that healthcare providers’ lack of understanding and sensitivity to Muslims and their traditions have facilitated potential or directly caused healthcare conflicts. In one study, it was discovered that healthcare providers’ cultural insensitivity and ignorance about Islamic beliefs hindered access to healthcare services in Australia (Tsianakas & Liamputtong 2002, cited in Simpson & Carter 2008). Rassool (2000) argued that caring
CN
from an Islamic perspective is not represented well in Eurocentric nursing literature and that there is a widespread misunderstanding in the concept and practice of Islam within the Western context of healthcare and nursing practice. The growing multiculturalism and changing demographics in Australia and around the world have lead to an increased diversity of needs that requires accommodation by a healthcare system that is embedded in Western culture. As a result, considerable cultural clashes may arise when Muslim patients experience hospitalisation in a non-Islamic healthcare facility and receive care from health care providers with limited knowledge about specific Muslim needs (Mohammadi, Evans & Jones 2007). Publications by pioneers in this field such as Drs Akram Omeri, Afaf Meleis and Linda Luna have established the foundations for much needed study in this area. Moreover, understanding the basic tenets and common concepts of Islam provides the basis for learning about Muslim generic care beliefs and practices and culturally congruent health care practices.
BASIC TENETS OF ISLAM AND COMMON ISLAMIC CONCEPTS The word Islam in Arabic means peace, purity, submission and obedience. In the religious sense of the world, Islam is the act of submission to the Will of Allah (God) and obedience to his Law (‘Abd al ‘Ati 1998). A Muslim is a practitioner of Islam. Muslims believe that the Qur’an is the Word of God, that it was revealed to the prophet Muhammad through the angel Gabriel and is considered as man’s best guide to God’s truth and to eternal happiness (‘Abd al ‘Ati 1989; Hamid 1996). The Qur’an is the highest authority for information on Islam, followed by the Sunnah and Hadith of the Prophet. Sunnah refers to the actions and confirmations of the Prophet in matters pertaining to the meaning and practice of Islam. Narrative accounts depicting sayings of the prophet are referred to as Ahaadith (singular: hadith) (Badawi 1999). Volume 28, Issue 1–2, April 2008
CN
85
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 86
Hiba Wehbe-Alamah
There are five basic tenets or pillars of Islam: 1. The shahadah or declaration of faith, which states that there is no God but God and that Muhammad is the messenger of God: Professing this declaration is key to joining the global community of Muslim believers (Hodge 2005). It is also considered a precursor to entering paradise, especially if it is the last statement uttered before death (Wehbe-Alamah 2005). 2. The Salat or prayer consists of praying five times a day during specific time spans while prostrating oneself in the direction of the holy city of Mecca (Husain 1995; Zeghidour 1994). Islamic prayer is a combination of intellectual meditation, spiritual devotion, moral elevation and physical exercise. It is usually preceded by ablution or Wudu’. There are various kinds of prayer including the obligatory or Fard prayer, the supererogatory or Sunnah prayer and the optional or Nafl prayer (‘Abd al ‘Ati 1998). 3. The Zakat or giving money to charity and the less fortunate is a means to purifying one’s wealth, establishing social justice and providing guidelines for positive human behavior and an equitable socioeconomic system (Husain 1995; Rassool 2000). The minimum rate of zakat is 2.5 % of the person’s estimated wealth (‘Abd al ‘Ati 1998). Zakat can be given to the poor, the wayfarer, the bankrupt, the needy converts, the captives, the collectors of zakat, or can be spent in the cause of God (Hamid 1996). 4. The Sawm or fasting during the month of Ramadan (Husain 1995): During that Islamic lunar month, Muslims are required to refrain from all food, drink and sexual relations from dawn to sunset. The Holy Qur’an was revealed to Prophet Muhammad during the month of Ramadan.Therefore, Muslims intensify their salat, zakat and reading of the Qur’an during that month (Hamid 1996). Fasting is considered a physical and spiritual purification act and a means 86
CN
Volume 28, Issue 1–2, April 2008
to reacquaint oneself with the physical sensation of hunger to foster empathy towards the poor. Muslims are exempt from fasting if ill or if traveling but must make up the missing days of fasting at a later date. This rule also applies to menstruating and postpartum women (Connelly et al 1999). 5. The Hajj or pilgrimage to the city of Mecca at least once in a person’s life span: This is considered an obligatory duty to every responsible Muslim, male or female, provided he/she is mentally, financially and physically able (‘Abd al ‘Ati 1998). In addition, Islam emphasises the concepts of: (a) Halal, which refers to permitted foods and actions considered to be lawful and permissible according to the tenets of Islam; (b) Haram which describes foods and conduct that are unlawful and prohibited, such as the consumption of pork and alcohol; and (c) Fard, which refers to compulsory actions that must be done according to Islamic Law or Shari’a such as prayer. It also stresses the concepts of: (a) Mustahab, which refers to acts which are recommended in the Sunnah of the Prophet, such as cleaning the teeth regularly before praying, and; (b) Makruh, which designates foods and actions that are disliked and discouraged (but not prohibited) by Islam such as divorce. (Hamid 1996; Husain 1995; Luna 1989)
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO THE ROLE OF WOMEN IN ISLAM Islam regards that, in the sight of God, all human beings are equal, but not necessarily identical. People differ in their abilities, potentials, ambitions and wealth. The only distinctions recognised by God are that of anatomy and piety (‘Abd al ‘Ati 1998; Wadud 1999). Islam
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 87
Bridging generic and professional care practices for Muslim patients regards women as independent members of society who are equal to men concerning basic human rights, pursuit of education and knowledge, freedom of expression, initiating enterprise and owning property independently (‘Abd al ‘Ati 1998). Men and women are complementary and not subservient to each other. Prophet Muhammad said: ‘I command you to be kind to women … The best of you is the best to his family/wife’ (Badawi 1999: 26). He is also reported to have said: ‘The quest for knowledge and science is obligatory upon every Muslim man and woman’ (Hassan 2000: 55). The Qur’an makes it clear that both men and women are equally capable of virtue and weakness and equally meritorious. Both genders are on equal footing before God; the belief in the superiority of men over women is not congruent with the teachings of Islam, but is merely a reflection of culturally-bound opinions (Badawi 1999). There are many variations in Muslim countries as far as cultural beliefs, practices, traditions and attitudes about women.These range from the extremely conservative to the more liberal. Many Muslim women seek higher graduate level education. In Egypt, women have been attending universities since the 1920s. In the United Arab Emirates, 70% of enrollees in Science and Technology University are females. Between 1990 and 1991, female students who were enrolled in biological science courses in Bahrain accounted for 68% of the total student population, compared to 67% in Kuwait, 69% in Qatar, 48% in Lebanon and 50% in Oman (Hasan 2000).Women across the Arab and Muslim world are increasingly becoming empowered to make informed health related decisions through education.
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO THE CAREGIVING PROCESS Many Muslims like Lebanese and Syrians classify caregiving as a responsibility shared by individ-
CN
ual, family and community members, regardless of diversities in age or gender. Family members including children, spouses, siblings, aunts, uncles and grandparents, as well as friends, neighbors and social acquaintances are all expected to participate in the caregiving process to varying degrees (Wehbe-Alamah 1999, 2005). While immediate family members and close relatives tend to provide financial, emotional and physical care community members are encouraged to do the same and to assist in the provision of spiritual care. Consequently, visiting and praying for the sick is valued by Lebanese, Syrian and other Muslims and is considered a cultural, social and religious obligation as well as a source of blessing (Halligan 2006, Rashidi & Rajaram 2001;Wehbe-Alamah 2005, 2006). In addition, providing financial care is regarded as secondary to safeguarding and protecting people’s honor and pride and may be carried out in a confidential and/or anonymous manner.
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS RELATED TO HEALTH AND ILLNESS Muslims believe health to be a blessing from God and attribute to it spiritual, physical, emotional and psychological dimensions that involve the well-being of the body, mind and soul. Health is also considered to be a prerequisite to give care to others as well as a requirement for and a contributor to one’s faith.The rationale is that illness hinders individuals from engaging in the caregiving role and from performing required religious activities such as fasting and the five mandatory daily prayers (WehbeAlamah 1999, 2005). In addition, health is promoted and enhanced by the application of Islamic religious teachings which call for abstaining from matters that are harmful to health (such as alcohol, illicit drugs, excessive eating, sexual promiscuity, homosexuality, pork products and its derivatives including gelatin) and engaging in health promoting practices (such as
Volume 28, Issue 1–2, April 2008
CN
87
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 88
Hiba Wehbe-Alamah
prayers, meditation, cleanliness, fasting, ablution, breastfeeding) (Mughees 2006; WehbeAlamah 1999, 2005). Pork meat and fat are considered unlawful because pigs are scavenging and omnivorous animals. They have no necks and therefore cannot be slaughtered according to Islamic law. Historically, pigs have been linked to parasitic infections such as trichinosis and their fat has been associated with the development of atherosclerosis (Shamsi 1999). The vast majority of practicing Muslims still do not consume pork products; however, some liberal Muslims who do not strictly adhere to Islamic teachings may not necessarily abide by this religious commandment. Most Muslims believe that illness is a test of one’s faith in God and a blessing in disguise as a means of atonement for sins of the past.Therefore, it is considered a sign of love from God and a physiologic and religious ‘wakeup call’ that allows for self-reflection and enhanced spiritual connections and meditation. At the same time, Muslims believe that illness is an occasion for engaging in Salat or prayer, charity, Zikr or remembrance of God, asking for forgiveness, reading the holy book (Qur’an) and behaving with patience (Mughees 2006). Muslims also believe that God is the ultimate healer and that illness is God’s will.They also believe that their body is a gift from God and that they should therefore care for it. In addition, illness is linked to biological and physiological causes and therefore requires medical and other professional attention (Wehbe-Alamah 1999, 2005). Consequently, they are encouraged to pay attention not only to their own personal well-being but the health of other individuals and the public and as a result, most Muslims will seek modern medicine and healthcare services (Bahar et al 2005; Lawrence & Rozmus 2001).
as a result abide by certain dietary principles and restrictions aimed at keeping the body in an optimal state of health. Substances that are considered to be harmful to the intelligence or intoxicant to the body are considered to be unlawful, forbidden, or haram. This includes alcohol and alcohol-based medications (such as cough syrup) except when there is no non-alcoholic alternative, as well as mind-altering drugs such as cocaine and marijuana (Rashidi & Rajaram 2001). Other forbidden foods include the meat of wild animals that use their claws or teeth to kill their prey (Gulam 2003). In addition, blood of dead animals, pork products such as bacon, ham and lard, as well as pork derivatives such as gelatin and insulin are considered to be haram foods. Many Muslims will refuse to eat meat that is bloody or slightly cooked, consume hospital-served gelatin, or take gelatin-encapsulated medications or vitamins and drugs that contain gelatin as an ingredient unless the gelatin has been confirmed to be derived from a lawful or halal source. However, Islam does allow Muslims to consume medications with pork-derived gelatin if there are no halal alternatives (Lawrence & Rozmus 2001; Wehbe-Alamah 2006, 2007). Although Islam prohibits the consumption of the blood of dead animals, it does not forbid the use of blood transfusions in hospital settings (Gulam 2003). While Muslims are allowed to eat meat slaughtered and prepared by the People of the Book such as Jewish and Christians, some of them will only consume halal meats that are prepared according to the Muslim law.The concept of halal involves the recitation of a prayer to God (Allah) while slaughtering an animal to commemorate that the animal is a blessed creature of God that is being killed for human sustenance (Gulam 2003). When admitted to the hospital setting, Muslims who adhere strictly to halal principles may request to have their own TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRAC- meals brought from home or choose vegetarian TICES RELATED TO DIETARY NEEDS or seafood alternatives from the hospital menu. During the holy month of Ramadan, healthy Muslims view the body as a gift from God and 88
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 89
Bridging generic and professional care practices for Muslim patients practicing Muslims all around the world engage in the fasting process. This practice involves abstaining from food, water, medications, sexual activity and smoking from the break of dawn through sunset. Muslim women who are pregnant or breastfeeding during that month are excused but are not forbidden from fasting (Ball & Haque 2003; Cassar 2006; Wehbe-Alamah 1999, 2005). Sick individuals are also exempt from fasting. Any missed fasting days are usually made up at a later date. Muslims who have diabetes and other individuals who need daily medications require adjustments to their medical regimen during the month of Ramadan.The timing of this month changes every year as it follows a lunar versus Gregorian calendar.
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO DRESS, PRIVACY, MODESTY, TOUCH, GENDER RELATIONS AND EYE CONTACT Modesty is an important concern and value for the vast majority of Muslims.This is particularly true for Muslim women. The traditional dress for conservative practicing Muslim women involves the use of loose clothing that covers the entire body with the exception of the hands and face and does not reveal its shape or curvatures. Long skirts, lengthy sleeves and head coverings are typically used (Cassar 2006). However, diverse cultures have different ethnic displays of what is considered to be an acceptable mode of dress. In Syria and Jordan many (but not all) Muslim women choose to wear a coat or Jilbab on top of their everyday clothing. In Saudi Arabia and Iran, women wear a black robe known as Abaya or Chador over their garments. Some even cover their faces. In Pakistan, most women wear long roomy tunics and pants sets known as Shalwar Kameez. It is important to note, however, that not all Muslim women adhere strictly to the Islamic dress code. Many liberal Muslim women have chosen to adopt the Western dress style.
CN
Regardless of which form of dress a conservative Muslim woman uses, there is an strong need among them to maintain privacy and modesty. Many Muslim women request to be draped as much as possible during medical or nursing procedures to safeguard their dignity. Caps are often asked for to cover the hair in instances were traditional Muslim head coverings are not allowed. There are numerous accounts that depict requests for signs at the hospital room door prohibiting men from entering the room of a Muslim woman without first asking permission to allow adequate time for the woman to cover her hair (Wehbe-Alamah 1999, 2005). Other generic care practices aimed at maintaining modesty and privacy include requesting a same sex healthcare provider when possible. Exceptions to this request occur when faced with an emergency situation or in cases were no competent same sex healthcare providers are available (D’avanzo & Geissler 2003 cited in Cassar 2006: 28).The rationale behind this prohibition is to minimise unlawful male–female touching and unnecessary body exposure to a person of opposite gender. In addition, while some Muslim men and women shake hands with or hug members of the opposite sex, many do not and as a result a simple pat on the back might make them feel uncomfortable. Nurses and other healthcare providers caring for Muslim patients of the same gender do not have to fear touching their patients as this rule applies only to members of the opposite sex (Lawrence & Rozmus 2001). Furthermore, Muslim men and women are prohibited from being alone in private except with their spouses, children, parents, uncles, aunts, father-in-law or mother-in-law (Rashidi & Rajaram 2001). Hence, many Muslim patients will request to have a chaperone or a family member stay with them during procedures involving a healthcare provider of the opposite sex. In addition, Muslim men and women who are prohibited to be alone with each other as explained above are discouraged from looking
Volume 28, Issue 1–2, April 2008
CN
89
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 90
Hiba Wehbe-Alamah
directly into each other’s faces (eyes) for prolonged periods of time: the holy book of Islam, the Qur’an, directs Muslims of both genders to lower their gaze (Rashidi & Rajaram 2001). What is considered to be an application of one’s religious faith by Muslims may be misinterpreted by non-Muslim health care providers as disinterest or disrespect. Similarly, Muslim healthcare providers who avoid direct and prolonged eye contact with non-Muslim patients or colleagues of the opposite sex risk being misunderstood as well as stereotyped (Wehbe-Alamah 2007). Finally, it is important to note that it is a common belief among traditional Muslims that food and drink should be consumed with the right hand which is reserved for doing clean things. The left hand is often reserved to performing unclean tasks such as cleaning the private area after bathroom use. As a result, Muslim patients will accept medications handed to them with the right hand but may refuse to take them if they were distributed to them with the left hand.
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO ABORTION AND CONTRACEPTION Induced abortion after 120 days of gestation is considered a mortal sin unless the pregnancy poses a serious threat to the mother’s life (Bahar et al 2005; Mughees 2006;Wehbe-Alamah 2005). In a study conducted by Bahar et al (2005), it was discovered that many Turkish Muslim women believe that women who have an induced abortion after being pregnant for four months will be forced to eat their babies in the next world. The authors also reported that taking Paracetamol or Digitoxin pills, hitting the groin, drinking the juice of boiled onions and beans and placing soap in the vagina while taking ephedrine were generic (folk) practices used by Turkish women to induce abortion. On the other hand, reversible methods of 90
CN
Volume 28, Issue 1–2, April 2008
birth control are not forbidden in Islam in contrast to nonreversible ones such as tubal ligation and vasectomy, which are considered unlawful (Mughees 2006; Wehbe-Alamah 1999, 2005). Use of oral contraceptives and/or intrauterine devices is popular among Lebanese, Syrian, Jordanian and Turkish Muslim women (Bahar et al 2005; Kridli & Newton 2005; Wehbe-Alamah 1999, 2005). Other birth control methods used by Muslim women and men include diaphragms, spermicides, condoms, the rhythm method and coitus interruptus. In vitro fertilisation and artificial insemination are permitted in Islam as long as the process involves the sperm or egg of the married couple (Mughees 2006; WehbeAlamah 1999, 2005).
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO BIRTH Muslims believe that a special prayer should be whispered in both baby’s ears as soon as he/she is born to declare faith and protect the newborn from evil spirits (Cassar 2006; Wehbe-Alamah 2005). This role is typically assigned to fathers but is not solely reserved for them. Additionally, anyone who handles the baby is expected to verbalise the name of God and/or expressions such as MashaAllah (What God wills) or SubhanaAllah (Glory be to God), to ward off evil. Furthermore, charms and amulets containing words or verses from the Qur’an are usually pinned to the clothing of newborns to shield them from the evil eye. Blue beads are sometimes used for the same rationale although recent studies have revealed that their use is becoming increasingly controversial among Lebanese and Syrian Muslims in the USA due to a lack of religious or scientific evidence related to the success of this practice in warding off the evil eye (Wehbe-Alamah 1999, 2005). Circumcision is a religious requirement for all male Muslims. However, this procedure does not have to be performed by a religious leader. It is the norm for Lebanese and Syrian Muslims
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 91
Bridging generic and professional care practices for Muslim patients in the USA to have their male babies circumcised before they are discharged from the hospital (Wehbe-Alamah 1999, 2005). On the other hand, the holy book of Muslims, the Qur’an, does not support female circumcision, which is commonly referred to as female genital mutilation or clitoridectomy. This procedure, which ranges from removing the clitoral prepuce to the removal of the clitoris, labia minora and most of the labia majora, is considered a controversial subject among Muslims from diverse cultural backgrounds (Lawrence & Rozmus 2001). While this practice is especially prevalent in sub-Saharan Africa and in countries along the Horn of Africa, it is virtually non-existent in countries such as Lebanon and Syria.This procedure is prohibited under Australian law (Gulam 2003). In the USA, this practice is considered illegal for girls under the age of 18 years (United States Department of Health & Human Services 2005). Many Muslims around the world celebrate the birth of their newborn with a banquet celebration called Aqiqah following the example of Prophet Muhammad.The celebration consists of inviting friends, relatives and neighbors to a feast preferably a week after the birth of the newborn. Meals with lamb or goat meat are typically served. Syrian Muslims in the USA continue to engage in this practice as do Muslims of other cultures (Wehbe-Alamah 2005).
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRACTICES RELATED TO DEATH AND BEREAVEMENT Like illness, death is regarded by Muslims as a reflection of God’s predestined will and as a test from Allah both to the dying person, the family and community. Muslims are expected to receive death with patience, prayers, reading the Qur’an and meditation (Cheraghi, Payne & Salsali 2005; Lawrence & Rozmus 2001) as they view death as a bridge to an eternal afterlife and as a journey towards resurrection and meeting
CN
God (Arshad, Horsfall & Yasin 2004; WehbeAlamah 2005). Proper burials are required for all dead Muslims including for foetuses 120 days or older who were miscarried or who died in utero (Gulam 2003; Mughees 2006). All children are considered to be innocent in Islam and their soul is believed to ascend directly to paradise after death. Muslims believe that dead children wait for their parents at the gates of heaven and that a great reward in the afterlife awaits the parents of dead children especially if they faced these deaths with Sabr or patience–self-control in this lifetime (Arshad et al 2004). When faced with death, Muslims tend to engage in certain generic (folk) care practices: they may request to face the direction of prayer which is Mecca in Saudi Arabia. In the USA, Muslim patients or their families may ask to have the hospital bed repositioned to face the North East direction whereas in Australia they may demand to face the West-North-West direction (Arshad et al 2004; Gulam 2003; Wehbe-Alamah 1999, 2005). In addition, the dying patient is reminded to deliver the Shahada or testimony of faith either directly or indirectly.The Shahada consists of saying: There is no God but Allah (God) and Muhammad is the Messenger of Allah (God). Casual recitation of the above mentioned statement in front of a dying Muslim patient serves as an indirect reminder of the need to make this final proclamation of faith. It is believed that death that coincides with the uttering of Shahada can facilitate one’s admittance to heaven (Mughees 2006;Wehbe-Alamah 2007). Reading the Qur’an and offering prayers and supplications are additional generic (folk) care practices surrounding death and the dying process for Muslims.These actions are believed to facilitate a peaceful departure of the soul and to plead for the welfare of the dying person in the afterlife (Arshad et al 2004; Lawrence & Rozmus 2001). In addition, religious or other artifacts that prolong the suffering or dying
Volume 28, Issue 1–2, April 2008
CN
91
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 92
Hiba Wehbe-Alamah
process of Muslims should be removed from the physical environment of a dying patient. In a study conducted with Syrian Muslims in the USA, it was discovered that crosses, statues, magazines, or picture frames portraying living creatures were believed to keep the angel of death away, which would lengthen the duration of anguish associated with the dying process. As a result, Syrian Muslims resorted to covering these items or removing them from the room of dying friends or relatives (Wehbe-Alamah 2005). Following death, special rituals are required for dead Muslims. First, the dead should only be touched by members of the same sex and preferably by Muslims.The body should be handled minimally and with great gentleness and respect as it is believed to feel pain and pressure (Komaromy 2004; Mughees 2006). Second, the eyes are closed, the lower jaw is bandaged to the head to avoid a gaping mouth, the joints are flexed and the body is straightened. Modesty is to be preserved at all times especially during the ritual washing of the body called Ghusul and its subsequent shrouding with a white garment resembling a sheet called Kafan (Arshad et al 2004; Gulam 2003;Wehbe-Alamah 2005). It is highly preferred to bury the dead within 24 hours of death as the soul is believed to feel pain until it is buried. This is one reason why postmortem examinations are discouraged in Islam, unless required by law. In addition, autopsies and body embalming are disliked because they are perceived to be associated with disfigurement of the body that belongs to God (Arshad et al 2004; Komaromy 2004; Lawrence & Rozmus 2001). Prior to burial, the body is usually taken to the community’s mosque for Janaza prayer, a special prayer ritual that precedes the burial of dead Muslims. Following the Janaza, the body is taken for entombment in a Muslim cemetery. While Muslims prefer to bury their dead directly in the soil without a coffin, the laws in the USA enforce the use of coffins for burial. Many Arab American Muslims such as Lebanese and 92
CN
Volume 28, Issue 1–2, April 2008
Syrians line the inside of the coffins with dirt to accommodate this legal requirement while fulfilling their religious obligation at the same time (Arshad et al 2004;Wehbe-Alamah 1999, 2005). Cremation is prohibited in Islam and is considered equivalent to the punishment of Hell (Komaromy 2004). Grief expressions following death and during the bereavement process tend to be diverse and range from quiet stoicism characterised by selfcontrol and patience to loud crying and wailing. A remarkable show of reliance on God and faith are often exhibited. Offering condolences to the bereaved is considered to be a Muslim duty and a virtuous act. Sympathies are typically offered during (but not limited to) the first three days of mourning. The Muslim community will often support the family of the deceased following death. Friends, extended family and community members often visit, cook food and undertake childcare activities for the family of the deceased (Arshad et al 2004; Lawrence & Rozmus 2001). In two different ethnonursing studies, Lebanese and Syrian Muslims in Midwestern USA cities were observed to organise circles for Qur’an recitations and supplications on behalf of the deceased, in addition the above mentioned practices (Wehbe-Alamah 1999, 2005).
TRADITIONAL MUSLIM GENERIC (FOLK) CARE BELIEFS AND PRAC-
TICES RELATED TO HIV AND AIDS The religion of Islam promotes chastity and discourages extra-marital relations, illicit drug use and homosexuality. In most Arab and Islamic countries, contracting HIV or AIDS is perceived to be associated with sexual promiscuity, gay– lesbian relationships, and/or unlawful drug use. This perception has lead to the development of a stigma associated with the disease coupled with feelings of shame and guilt. Most Arab and Islamic leaders initially denied the existence of HIV/AIDS related problems in their countries and did not engage in any preventive or educational programs addressing this pandemic. The
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 93
Bridging generic and professional care practices for Muslim patients Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated that in 2005, nearly 1 million people from North Africa, the Middle East and predominantly Muslim Asia were infected with HIV (Kelly & Eberstadt 2005). Many countries, including but not limited to Thailand, Iran and Bangladesh have more recently acknowledged their epidemics and taken active steps to find ways to control and prevent HIV infections. AIDS education programs have been incorporated in public schools and other sectors of society. In 2006, the first HIV/AIDS training for female religious leaders in the Arab world was held in Tripoli, Libya and addressed the rights of women and children to protect themselves from HIV infection. In 2007, 300 Christian and Muslim religious leaders from 20 Arab countries met in Cairo and launched the first network focused on HIV/ AIDS. The network’s goal was to promote chastity and dignity and provide support, spiritual counseling and care for people living with HIV/AIDS and their families. It sought to highlight the links between HIV/AIDS and development, governance, gender and human rights and addressed causes of HIV/AIDS, including poverty, at both the national and regional levels (Berger & Mendez 2007).While active steps are being taken to halt the spread of HIV/AIDS pandemics, a diagnosis with HIV/AIDS remains a taboo and a source of shame and guilt for many Muslims.
USE OF LEININGER’S CULTURE CARE MODES TO PROVIDE CULTURALLY CONGRUENT CARE Nurses and other health care professionals can rely on their knowledge of Muslim generic care beliefs and practices while using Leininger’s culture care modes to bridge the gap between generic or folk (emic) and professional (etic) care practices and to consequently promote culturally congruent care. Leininger’s culture care modes include: Culture care preservation and/ or maintenance, culture care accommodation
CN
and/or negotiation and culture care repatterning and/or restructuring. Culture care preservation and/or maintenance is defined by Leininger as ‘… those assistive, supportive, facilitative, or enabling professional acts or decisions that help cultures retain, preserve, or maintain beneficial care beliefs and values and to face handicaps and death’ (Leininger & McFarland 2006: 8). Nurses and other healthcare professionals can preserve the culture care of more traditional Muslim patients by allowing them to consume home cooked meals in the hospital setting, especially if the health institution lacks the ability to prepare food according to Islamic law. They can also maintain the privacy and modesty of these patients through avoidance of unnecessary body exposure, prolonged direct eye contact and unlawful male–female touching as well as through assigning same sex healthcare providers when possible. Offering medications and food trays with the right hand and avoiding the initiation of hand shaking or hugging of patients of the opposite sex are other nursing actions designed to maintain the culture care of traditional Muslims. When it comes to newborn care, nurses must not interfere with the recitation of prayer in the baby’s ears and should not remove any pinned charms and amulets from the infant’s clothing without seeking prior parental permission. Culture care accommodation and/or negotiation refers to ‘those assistive, accommodating, facilitative, or enabling creative provider care actions or decisions that help cultures adapt to or negotiate with others for culturally congruent, safe and effective care for their health, well-being, or to deal with illness or dying’ (Leininger & McFarland 2006: 8). Nurses can accommodate their Muslim patients, relatives and community members by providing them with a private and clean area for prayer and/or Qur’an recitation especially when a death is imminent.They can also negotiate with them in relation to visitation procedures especially given
Volume 28, Issue 1–2, April 2008
CN
93
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 94
Hiba Wehbe-Alamah
that visiting the sick by many relatives and friends is considered to be a religious, cultural and social duty. In addition, accommodation can be carried out in relation to prescribing gelatin and alcohol-free alternatives to medications and vitamins and adjustments to medication and other medical-nursing regimens can be made for fasting Muslim patients during the holy month of Ramadan. Nurses are also in the position to be able to negotiate with the kitchen staff to arrange for seafood and/or vegetarian alternatives for Muslim patients who strictly adhere to halal diets. Additional accommodations for providing culturally congruent care to Muslim female patients may include posting signs at the door (upon request) and asking for men to knock on the door and seek permission before entering the room to allow for time to cover the hair and secure patient modesty. Likewise, male nurses, nurse practitioners, physicians, or other health care professionals may accommodate female Muslim patients by arranging for the presence of a female chaperone or family member during procedures that breach traditional Muslims’ modesty or expose their private body parts. Furthermore, nurses may change the location of hospital beds to face the direction of prayer (Mecca in Saudi Arabia) to accommodate the needs of Muslim patients who wish to pray in bed or who are faced with impending death. Moreover, for dying Muslim patients, nurses may remove or cover (upon request) religious or other artifacts that portray living creatures in the patient’s hospital room. Following death, nurses may assist the family of the deceased by facilitating the discharge process given that burial is preferred to take place within 24 hours. Handling the body of dead Muslims should be minimized and carried out with extreme caution and respect. Nurses not sharing the same gender as the deceased are discouraged from touching the body. Culture care repatterning and/or restructuring include ‘… those assistive, supportive, 94
CN
Volume 28, Issue 1–2, April 2008
facilitative, or enabling professional actions and mutual decisions that would help people to reorder, change, modify, or restructure their lifeways and institutions for better (or beneficial) health care patterns, practices, or outcomes’ (Leininger & McFarland 2006: 8). Nurses who discover harmful beliefs and practices used by patients have a responsibility to educate their clients about the dangers and consequences of such actions and may strive to collectively explore healthy alternatives in order to reach mutual decisions that restructure the lifeways of their patients. Consequently, nurses caring for Turkish or any other Muslim women who engage in any of the generic care practices depicted earlier in this paper that endanger health in relation to inducing abortion may counsel these women about the potential harmful consequences of such actions and investigate healthy alternatives such as the use of preventative birth control methods (contraception). In addition, nurses may educate African and other Muslim women (and possibly men) who engage in or advocate for female genital circumcision about the adverse effects and ramifications of female genital mutilation and together explore culturally acceptable substitutes. Finally, health care providers may engage in culturally sensitive education in relation to spread and prevention of HIV/AIDS keeping in mind the generic care beliefs that may be associated with this illness.
CONCLUSION As health care professionals, we have the duty to deliver holistic and culture-specific health care services to our patients. Ignoring unique individual cultural interpretations, beliefs and practices of diverse health related issues prevents providing culturally congruent care. Incorporating generic or folk (emic) care beliefs and practices in a professional (etic) plan of care facilitates the delivery of care that addresses professional scientific standards while attending to culture-specific needs and expectations of clients of diverse cultural backgrounds. Bridg-
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 95
Bridging generic and professional care practices for Muslim patients
CN
ing generic or folk (emic) and professional Bahar Z, Okcay H, Ozbicakci S, Beser A, Ustun B and Ozturk M (2005) The effects of Islam and (etic) care beliefs and practices through the use traditional practices on women’s health and of Leininger’s culture care modes not only proreproduction, Nursing Ethics 12(6): 557–570. motes culturally congruent care, but may also Ba-Yunus I and Siddiqui MM (1998) A report on lead to increased client satisfaction, a pleasant Muslim population in the United States of hospital stay, improved client cooperation and a America, Center for American Muslim Research faster recovery rate. Muslim patients are diverse & Information, Islamic Book Center, Richmond in their generic care beliefs and practices. As Hill, NY, in Rashidi A and Rajaram S (2001) nurses and professional healthcare providers, Culture care conflicts among Asian-Islamic we cannot assume that all Muslim patients share immigrant women in US hospitals, Holistic the traditional generic care beliefs and practices Nursing Practice 16(1): 55–64. discussed in this paper. Performing individual Ball C and Haque A (2003) Diversity in religious cultural assessments is crucial to discovering practice: implications of Islamic values in the cultural beliefs and needs and providing culturpublic workplace, Public Personnel Management ally congruent care practices. 32(3): 315–330. Berger R M and Mendez J (2007) Christians and References Muslims fighting AIDS, Sojourners Magazine ‘Abd al ‘Ati H (1998) Islam in Focus, Amana Publi36(3): 11. cations, Beltsville, MD. Cassar L (2006) Cultural expectations of Muslims Armanios F (2004) Congressional Research Service and Orthodox Jews in regard to pregnancy and Report for Congress, Congressional Research the postpartum period: a study in comparison Service, accessed at http://www.fas.org/irp and contrast, International Journal of Childbirth /crs/RS21745.pdf on 12 February 2008. Education 21(2): 27. Arshad M, Horsfall A and Yasin R (2004) PregCheraghi M, Payne S and Salsali M (2005) Spiritual nancy loss – the Islamic perspective, British aspects of end-of-life care for Muslim patients: Journal of Midwifery 12(8): 481–484. experiences from Iran, International Journal of Australian Bureau of Statistics (2007a) 2006 Census Palliative Nursing 11(9): 468–474. QuickStats:Australia, accessed at http://www Connelly M, Hammad A, Hassoun R, Kysia R and .censusdata.abs.gov.au/ABSNavigation/prenav Rabah R (1999) Guide to Arab culture: Health care /ProductSelect?newproducttype=QuickStats& delivery to the Arab American community, Access btnSelectProduct=View+QuickStats+%3E&c Community Health Center, Dearborn, ollection=Census&period=2006&areacode=0 Michigan. &geography=&method=&productlabel=&pro D’avanzo CE and Geissler EM (2003) Cultural ducttype=&topic=&navmapdisplayed=true&ja Health Assessment, Mosby, St Louis, cited in vascript=true&breadcrumb=LP&topholder=0 Cassar L (2006) Cultural expectations of &leftholder=0¤taction=201&action=4 Muslims and Orthodox Jews in regard to 01&textversion=false on 05 July 2007. pregnancy and the postpartum period: a study Australian Bureau of Statistics (2007b) Year Book in comparison and contrast, International Australia 2007: Cultural Diversity, accessed at Journal of Childbirth Education 21(2): 27. http://www.abs.gov.au/AUSSTATS/
[email protected] Gulam H (2003) Clinical update: Care of the /bb8db737e2af84b8ca2571780015701e/7056 Muslim patient, Australian Nursing Journal F80A147D09D3CA25723600006532?opendoc 11(2): 23–5. ument on 5 July 2007. Halligan P (2006) Transcultural care, World of Irish Nursing & Midwifery 14(8): 34–34. Badawi J (1999) Gender Equity in Islam: Basic PrinciHamid AW (1996) Islam Natural Way, Kazi ples, American Trust Publications, Indianapolis Publications, Inc, Chicago, IL. IN.
Volume 28, Issue 1–2, April 2008
CN
95
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 96
Hiba Wehbe-Alamah
Hassan F (2000) Islamic women in Science, Science 290(5489): 55–56. Hodge D (2005) Social work and the house of Islam: Orienting practitioners to the beliefs and values of Muslims in the United States, Social Work 50(2): 162–173. Husain S (1995) What do we know about Islam? Peter Bedricks Books, NewYork. Kelly L and Eberstadt N (2005) The Muslim face of AIDS, Foreign Policy 149: 42–48. Komaromy C (2004) Continuing professional development: Cultural diversity in death and dying, Nursing Management – UK 11(8): 32–36. Kridli S and Newton S (2005) Jordanian married Muslim women’s intentions to use oral contraceptives, International Nursing Review 52(2): 109–114. Lawrence P and Rozmus C (2001) Culturally sensitive care of the Muslim patient, Journal of Transcultural Nursing 12(3): 228–233. Leininger MM (1995) Transcultural Nursing: Concepts,Theories, Research, & Practice, 2nd edn, McGraw-Hill, New York. Leininger MM and McFarland MR (2002) Transcultural Nursing: Concepts,Theories, Research and Practice, 3rd edn, McGraw-Hill Medical, New York. Leininger MM and McFarland MR (2006) Culture Care Diversity and Universality: A Worldwide Nursing Theory, 2nd edn, Jones & Bartlett, Sudbury MA. Luna L (1989) Care and cultural context of Lebanese Muslims in an urban U.S. community: An ethnographic and ethnonursing study conceptualized within Leininger’s theory. Unpublished Doctoral dissertation,Wayne State University, Detroit MI. Mohammadi N, Evans D and Jones T (2007) Muslims in Australian hospitals:The clash of cultures, International Journal of Nursing Practice 1: 310–315. Mughees A (2006) Better caring for Muslim patients,World of Irish Nursing & Midwifery 14(7): 24–25. Rashidi A and Rajaram S (2001) Culture care conflicts among Asian-Islamic immigrant 96
CN
Volume 28, Issue 1–2, April 2008
women in US hospitals, Holistic Nursing Practice 16(1): 55–64. Rassool G (2000) The crescent and Islam: healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring, Journal of Advanced Nursing 32(6): 1476–1484. Shamsi R (1999) Why Islam forbids pork, The MuslimWorld League Journal, accessed at http: //islamic-world.net/sister/h1.htm on 13 February 2008. Simpson J and Carter K (2008) Muslim women’s experiences with health care providers in a rural area of the United States, Journal of Transcultural Nursing 19(1): 16–23. Tsianakas V and Liamputtong P (2002) What women from an Islamic background in Australia say about care in pregnancy and prenatal testing, Midwifery 18: 25–34. Underwood SM, Shaikha L and Bakr D (1999) Veiled yet vulnerable: Breast cancer screening and the Muslim way of life, in Cancer Practitioner 7(6): 285–290, cited in Rashidi A and Rajaram S (2001) Culture care conflicts among AsianIslamic immigrant women in US hospitals, Holistic Nursing Practice 16(1): 55–64. United States Census Bureau (2005) 2005 American Community Survey data profile highlights, accessed at http://factfinder.census.gov/serv let/ACSSAFFFacts?_event=&geo_id=01000U S&_geoContext=01000US&_street=&_count y=&_cityTown=&_state=&_zip=&_lang=en &_sse=on&ActiveGeoDiv=&_useEV=&pctxt =fph&pgsl=010&_submenuId=factsheet_1&d s_name=null&_ci_nbr=null&qr_name=null& reg=null%3Anull&_keyword=&_industry= on 05 July 2007. United States Department of Health and Human Services (2005) Female genital cutting, accessed at http://www.4women.gov/FAQ/fgc.htm on 01 August 2007. Wadud A (1999) Qur’an and woman, Oxford University Press, New York. Wehbe-Alamah H (1999) Generic Health Care Beliefs, Expressions and Practices of Lebanese Muslims in two Urban U.S. Communities: A
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 97
Bridging generic and professional care practices for Muslim patients Mini Ethnonursing Study Conceptualized within Leininger’s Theory. Unpublished Master’s Thesis, Saginaw Valley State University, MI. Wehbe-Alamah H (2005) Generic and Professional Care Meanings, Beliefs, Expressions and Practices of Syrian Muslims living in the Midwestern United States. Doctoral dissertation, Duquesne University, Pittsburgh, PA. Accessible at: http://etd1.library.duq.edu/ theses/available/etd-11172005-122600 Wehbe-Alamah H (2007) Understanding How
CN
Racial & Ethnic Differences Affect the Delivery of Health Care in America – The Arab/Muslim Culture, Academic Presentation on 07 March 2007, University of Michigan-Flint. Zeghidour S (1994) I want to talk to God, Creative Education, Mankato MN. Zoucha R and Husted G (2000) The ethical dimensions of delivering culturally congruent nursing and health care, Issues in Mental Health Nursing 21(3): 325–340.
• • • C A L L F O R PA P E R S • • • A D VA N C E S
I N C O N T E M P O R A RY N U R S I N G A N D G E N D E R Guest edited by Professors Paula McGee, University of Central England, UK and Kim Walker, St Vincent’s Private Hospital, Australia
A peer-reviewed special issue (ISBN 978-1-921348-07-5) of Contemporary Nurse, publishing in 2009. DEADLINE FOR MANUSCRIPT SUBMISSIONS: 15 December 2008 We invite papers on all aspects of gender and nursing, including: Research papers about any aspect of gender and nursing care including methodological issues and topics that are under-addressed; Papers about gender orientation concerning lesbian, gay, bisexual, transgender or heterosexuality and gender reassignment; Race, ethnicity, culture, religion and gender; Relevant practice papers that provide examples of multi-professional practice or which address the practicalities, policy or managerial aspects of delivering services and care; Debate papers that address key issues relating to gender and nursing. Papers are invited for this special issue of Contemporary Nurse devoted to all aspects of gender and nursing, including: • Research papers about any aspect of gender and nursing care including methodological issues and topics that are under-addressed • Papers about gender orientation concerning lesbian, gay, bisexual, transgender or heterosexuality and gender reassignment
• Relevant practice papers that provide examples of multi-professional practice or which address the practicalities, policy or managerial aspects of delivering services and care • Debate papers that address key issues relating to gender and nursing
• Race, ethnicity, culture, religion and gender The Guest Editors would be pleased to discuss your submission in advance: Professor Paula McGee, Faculty of Health, University of Central England, Perry Barr, Birmingham B42 2SU, UK; Tel: 0121 331 53401; email
[email protected] Professor Kim Walker, Adjunct Professor, St Vincent’s Private Hospital, Darlinghurst NSW 2010, Australia; Tel: 02 8382 7442; email:
[email protected] Or send electronically to
[email protected] for automated distribution to the editors, indicating in the cover email that it is for the 2009 Special Issue of Contemporary Nurse on Nursing Gender. Instructions for Authors, past issues, and other details can be found on the website: http://www.contemporarynurse.com/author_guidelines.php
eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected] www.e-contentmanagement.com
Volume 28, Issue 1–2, April 2008
CN
97
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 98
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 98–100.
CN
EDITORIAL Towards a culturally competent nurse workforce RHONDA GRIFFITHS AM Professor of Nursing School of Nursing University of Western Sydney Sydney NSW, Australia and Director Centre for Applied Nursing Research Sydney South West Area Health Service Sydney NSW, Australia
T
he cultural diversity of Australia is considered to be a strength that will assist this nation to take advantage of, and meet the challenges that come with participating in the rapidly changing ‘global village’. A culturally diverse society provides its own challenges, and over the past 30 years state and federal Governments have disseminated a range of policies and initiated programs that provide frameworks and benchmarks for meeting the goals of access, equity and inclusiveness (Omeri 2003) for all people living in Australia. Responding to and accommodating cultural diversity poses particular challenges because of the intensely personal meaning that established cultural mores have for individuals, and the tendency for people to cling to their cultural heritage and, in some instances, biases. Health and education are the mainstays of a nation. Success in the arts, science, humanities and business requires people to have access to a range of educational options and access to quality health care. There is a plethora of research from the social, health and education disciplines that demonstrates unequivocally the nexus between these social foundations. There is also an
98
CN
Volume 28, Issue 1–2, April 2008
JOHN DALY Dean Faculty of Nursing Midwifery and Health University of Technology, Sydney NSW, Australia
increasing body of evidence to guide the application of that research to inform the everyday issues that arise in a diverse society. How is that cultural diversity reflected in education of clinicians and translated to the health system they work in? There is an expansive body of published, peer reviewed research that can be used by individuals and organisations to provide an evidence based approach to transcultural health care. The Australian National Review of Nursing Education Multicultural Nursing Education reviewed the ways in which nurses are currently prepared for multicultural practice (Commonwealth Department of Education, Science and Training [DEST] 2002). In that document cultural competence is described as: A set of congruent behaviours, attitudes and policies that come together in a system of agency or among professionals that enable effective interactions in a cross-cultural framework. (DEST 2002: 4) The report concluded that there has been an explosion of theories of cultural competence and literature describing its application. Exam-
CNJ 28_1_2_internal.qxd
30/07/2008
9:48 PM
Page 99
Editorial: Towards a culturally competent nurse workforce ples from international and local facilities were analysed and included in an extensive list of areas where theories of cultural competence had been applied to nursing in education, research, workforce planning, care delivery in general and speciality settings, and health promotion and community care. Individuals and organisations have a joint responsibility to create an environment that is conducive to and will foster cultural diversity, be prepared to commit to ongoing review, and when necessary initiate and support change (Omeri 2003). That joint responsibility is a theme that runs through the contemporary literature and is echoed by contributors in this special issue of Contemporary Nurse. In this section of the publication, Carolyn Rutledge et al (2008) describes an education program that uses multi media resources and experiential learning to assist clinicians overcome many of the barriers to cultural competence they experienced in their workplace.This program could be implemented or adapted to suit various situations to assist positive interactions with people from diverse cultures. While clinicians generally become aware of the construct of cultural competence through modelling by colleagues, CampinhaBacote (2008) suggests that the actions required to function at that level can also be learned by clinicians as part of their structured education programs. In a longitudinal study, Maltby and colleagues (2008) encouraged a cohort of baccalaureate nursing students to reflect on their attitudes towards nursing clients from diverse populations.The themes that emerged from the data namely: equal treatment; commitment to serve all clients; and ‘it’s not easy’, challenge clinicians on a daily basis. Papadopoulos et al (2008) developed and tested a tool to measure cultural competence of staff working in Child and Adolescent Mental Health services. Promoting a culture of cultural competence extends beyond client care. The workforce shortages of trained staff that is now a feature of health services, has resulted in the globalisation of the nursing work-
CN
force.The article by Brunero et al (2008) highlights an increasingly important issue for health services.The migration of the nursing workforce creates a need for health services to implement strategies that assist Australian trained nurses to appreciate the benefits of a culturally diverse workforce and assists overseas qualified nurses to weather the cultural clash they experience as they ‘rotate’ around the world. Three policy principles that are dominant in the multicultural policy agenda – access and equity and inclusiveness (Omeri 2003) – are also dominant in the health agenda. Best practice in health care for a multicultural society requires consideration of cultural as well as clinical imperatives. The needs of people from culturally diverse backgrounds must be taken into account when developing care. In some instances this will mean different approaches are appropriate, and the outcome of care may also be different. Having access to evidence is only one part of the formula for effective transcultural nursing. In all Western countries, the health sector consumes a large proportion of Government funding; however, we have little evidence to demonstrate the effectiveness of interventions, processes and models of care. Research has made a major contribution to health care, particularly in technology led areas for example pharmacology, diagnostics and surgery. Some interventions are outstandingly effective in reducing mortality and morbidity, and ‘high profile’ interventions receive attention. However, at the bedside, clinical decision making continues to reflect convention and tradition (Grimshaw & Eccles 2004; Grol & Grimshaw 2001; Johnson & Griffiths 2001). Why is this the case? A variety of reasons for the sustained theory/practice gap have been presented. The culture of health care facilities has been implicated, as has the nursing culture, clinical priorities, issues of leadership and communication and resources (Johnson & Griffiths 2001). Reasons for this situation have been proposed, including the task oriented nature of clinical
Volume 28, Issue 1–2, April 2008
CN
99
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 100
Rhonda Griffiths and John Daly
practice, the absence of guiding frameworks, and lack of detailed exploration about how to implement research. The notion of clinician-led research introduces an alternate paradigm to health services research that has challenged the traditionally designed and accustomed roles of researcher and clinician. Factors that militate against clinician led change have been proposed and include (Grol & Wensing 2004; Johnson & Griffiths 2001; Rycroft-Malone et al 2004): • lack of support and lack of authority to implement change; • lack of research training for clinicians; • the absence of organisational and research information systems; and • the constraining nature of the nursing role.
Getting evidence into practice Enacting strategies designed to promote social a responsibility at both the organisational and individual level.That is, providing quality care to a diverse population requires both systematic responses … and the delivery of care by skilled and sensitive providers. (Grol & Wensing 2004: 3). Despite the emphasis on evidence based care and the development of resources and support to assist clinicians to access evidence, the gap between the evidence and practice has not narrowed (Grol & Wensing 2004). Increasingly undergraduate and post graduate curricular include discrete learning opportunities to promote skills and knowledge to achieve cultural competence and outcomes against which learning can be measured. Nurses who translate those skills into clinical practice have the potential to change national health policy (Boyle 2000). Ignaz Semmelweis (1818–1865) and Joseph Lister (1827–1912) had the idea that infection was associated with poor hygiene by hospital staff. Although their colleagues forcefully rejected their hypothesis they persevered and were 100
CN
Volume 28, Issue 1–2, April 2008
vindicated. The researchers and clinicians who have contributed to this special issue of Contemporary Nurse have put out the challenge. Providing culturally competent care is a universal standard that, when achieved, will save and change lives for recipients and providers of health care.
References
Boyle J (2000) Transcultural nursing:Where do we go from here? Journal of Transcultural Nursing 11: 10–11. Brunero S, Smith J and Bates E (2008) Expectations and experiences of recently recruited overseas qualified nurses in Australia, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 101–110. Campinha-Bacote J (2008) Cultural desire:‘Caught’ or ‘taught’? Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 141–148. Commonwealth Department of Education Science and Training (DEST) (2002) National Review of Nursing Education. Multicultural Nursing Education. DEST, Canberra. Grimshaw J and Eccles M (2004) Is evidence-based implementation of evidence-based care possible? Medical Journal of Australia 180: S50–S51. Grol R and Grimshaw J (2001) From best evidence to best practice: Effective implementation of change in patient’s care. Lancet 363: 1225–1230. Grol R and Wensing M (2004) What drives change? Barriers to and incentives for achieving evidence-based practice. Medical Journal of Australia 180: S57–S60. Johnson M and Grifiths R (2001) Developing evidencebased clinicians. International Journal of Nursing Practice 7: 109–118. Maltby HJ (2008) A reflection on culture over time by Baccalaureate nursing students, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 111–118. Omeri A (2003) Meeting diversity challenges: Pathways of ‘advanced’ transcultural nursing practice in Australia. Contemporary Nurse 15(3): 175–187. Papadopoulos I, Tilki M and Ayling S (2008) Cultural competence in action for CAMHS: Development of a cultural competence assessment tool and training programme, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 129–140. Rutledge CM, Barham P,Wiles L, Benjamin RS, Eaton P and Palmer K (2008) Integrative simulation: A novel approach to educating culturally competent nurses, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 119–128. Rycroft-Malone J, Harvey G, Seers K, Kitson A, McCormack B and Titchen A (2004) An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing 13: 913–924.
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 101
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 101–110.
Expectations and experiences of recently recruited overseas qualified nurses in Australia ABSTRACT
Key Words overseas qualified nurse; nursing; culture and linguistic diversity; retention; recruitment
The overseas qualified nurse (OQN) has become an important part of the Australian nursing workforce. Efforts to enhance their adjustment to work and life in Australia have been recommended in the literature.This study examines the experiences and needs of a group of OQNs at a major metropolitan tertiary referral hospital in Australia. Using a descriptive survey, 56 nurses reported their experiences with three major themes emerging, career and lifestyle opportunities, differences in practice and homesickness. Nurses from culturally and linguistically diverse backgrounds reported not being employed in their chosen speciality and rating the utility of ward and hospital orientations more positively when compared to English speaking background nurses. From the study results an organisational and a personal approach has been undertaken to aid in the adjustment of OQNs into the nursing workforce. Received 30 March 2007
Accepted 19 March 2008
CN
SCOTT BRUNERO
JULIE SMITH
EMMA BATES
Department of Liaison Mental Health Nursing Prince of Wales Hospital Randwick NSW, Australia
Department of Liaison Mental Health Nursing Prince of Wales Hospital Randwick NSW, Australia
Department of Liaison Mental Health Nursing Prince of Wales Hospital Randwick NSW, Australia
INTRODUCTION
O
ver the past decade a deficit of Australian nurses has prompted active policies of international recruitment. In Australia a shortfall of 40 000 nurses by 2010 is predicted (Jeon &
Chenoworth 2007). In consequence, the overseas’ qualified nurse (OQN) has become an increasingly vital component of the Australian nursing workforce (Hawthorne 2001). Investment in providing appropriate support to enable
Volume 28, Issue 1–2, April 2008
CN
101
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 102
Scott Brunero, Julie Smith and Emma Bates
overseas nurses to adapt to working in a different health care system and settling in to life in Australia is regarded as essential (Jeon & Chenoworth 2007; Gerrish & Griffith 2004). In a recent systematic review of the literature Konno (2006) found 64 papers on the topic of OQNs in Australia. Two core themes emerge from this meta-synthesis. Firstly, overseas nurses found entry into Australian culture very difficult; and secondly they felt lonely and isolated, and experienced difficulty in settling in to nursing in Australia. Konno (2006) contends that the clash of cultures between OQNs and the dominant Australian culture should be addressed in dedicated transition programmes. Daniel, Chamberlain and Gordon (2001) in the United Kingdom (UK) explored the expectations and experiences of newly recruited Filipino nurses. Key factors that influenced their decision to work in the UK were improved prospects and better wages. Differences were also noted in their expectations of their new nursing role and their actual experience. Strategies reported as being helpful during this adjustment phase were: support services, culturally appropriate orientation programmes, training and opportunities for promotion.The literature suggests that problems in adjustment for OQNs may include: culture shock, homesickness, communication difficulties, social isolation, anxiety and accommodation issues (Daniel et al 2001). Similarly, Pilette (1989) reports that international nurses undergo a process of adjustment that frequently leads to cultural, professional and psychological dissonance. Pilette (1989) recommends that health care managers seek to understand this process of adjustment, and implement assimilation programmes to support international nurses, and ultimately retain them within the workforce. At an international level the International council of Nurses (ICN 2007), has set out a position statement on the ethical recruitment of nurses. The ICN recognises the right of nurses to migrate and notes the benefit to nursing out102
CN
Volume 28, Issue 1–2, April 2008
comes of the multicultural and learning opportunities gained by the process of migration.The ICN equally denounces where countries have failed to adequately plan for human resources gaps and also countries that haven’t addressed reasons why nurses leave the profession. The ICN makes it clear in this position statement that nurses have the right to proper orientation and ongoing constructive supervision/mentoring within the work environment (ICN 2007).
CULTURE-CARE STRATEGIES TO PROMOTE RETENTION OF OQNS Ideas that aim to strengthen retention rates and reduce the pressure on the continuous recruitment effort warrant consideration. A variety of interventions have been described in the literature and they include: employment of an international support nurse, mentorship programmes, country-specific orientation programmes, social programmes, intercultural communication courses and clinical supervision. Oxtoby (2003) explores the role of an ‘International Support Nurse’ in the UK. The role offers support and guidance to the new recruit to help them understand and deal with any culture shock they may experience.The educational component of the role involves the delivery of assertiveness training, rehearsing clinical scenarios and improving communication between different cultural groups. Ryan (2003) reports on a North American buddy programme describing the following as necessary for the OQNs adjustment. These are socialisation to the professional nursing role, acquisition of language and other communication skills, development of clinical and organisational workplace competence, availability of support systems and resources within the organisation. Gerrish and Griffith (2004) report on an evaluation of an adaptation programme.They delineated that the success of the programme was associated with the OQNs gaining professional registration, their fitness for practice, reducing the nurse
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 103
Expectations and experiences of recently recruited overseas qualified nurses
CN
vacancy factor, equality of opportunity, and pro- geted care-related interventions, to assist in their adjustment. moting a culture of valuing diversity.
ORGANISATIONAL APPROACHES
METHOD
Alexis and Chambers (2003) discuss the importance of the culturally competent environment, where its systems, agents and stakeholders all respond to the needs of the OQN, particularly when their needs are different from the dominant culture. In support of this view, Bruhn (1996) argues the case for creating organisations that have a climate of multiculturalism in healthcare. Bruhn (1996) suggests that multiculturalism begins with creating a climate of open participation, the encouragement of feedback and allowing control to be exercised at lower organisational levels. Davidhizar, Dowd and Newman Giger (1999) sees the role of the health care manager, as helping a diverse workforce to understand the differences between individuals and to facilitate their working together in a smooth and complimentary way. Davidhizar et al (1999) propose a transcultural model for evaluation of a new job culture, including items such as; communication, space, social organisation, time, environmental control, biological variations and a self assessment checklist as a strategy for adjusting to a new organisational culture. Senior nursing staff at the study site became increasingly aware of the challenges faced by recently arrived overseas nurses, when many sought out support due to adjustment problems. This prompted a discussion around what were the expectations, experiences, concerns and needs of the newly recruited overseas nurse. Furthermore could the organisation do better to facilitate the transition into a new culture, and a different health care system?
A descriptive survey was developed containing open and closed questions and was constructed from an examination of the literature.The survey was mailed to 150 nurses who had arrived at the hospital in the past 18 months.The study site is a major tertiary referral teaching hospital in Sydney, Australia, with approximately 550 beds. The survey contained three primary sections: 1. Demographic questions; age, country of origin, English speaking background status, country of origin, locality, nursing speciality, sex, length of time in Australia. 2. Participants were asked to rate on a 10point Likert scale the hospital, and ward orientation and overall satisfaction with the services provided. 3. Four open-ended questions were adapted from a study by Daniel and Chamberlain (2001) of Filipino nurses in the UK. They were: (a) Why did you decide to come and work at this hospital? (b) Before you left for Australia what were your expectations about living and working in Australia? (c) When you compare your experience of working at this hospital with hospitals outside of Australia, what are the main differences? (d) What do you regard as a barrier to staying longer at the hospital?
STUDY AIMS The aims of the study were to determine the care-related culture specific expectations and experiences of the overseas’ qualified nurse and to both recommend and implement local tar-
South Eastern Sydney Illawarra Area Health Service, Human Research Ethics Committee, granted ethics approval. Demographic variables have been summarised using descriptive statistics. All dichotomous and continuous variables were compared by English speaking background (ESB) and non-English speaking background (NESB) status, non-parametric chi square tests and Kruskal-Wallis tests were used for the analy-
Volume 28, Issue 1–2, April 2008
CN
103
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 104
Scott Brunero, Julie Smith and Emma Bates
sis. A content analysis was undertaken to identify the major themes of the open ended questions. Following the analysis process, the authors met to compare their coding of the themes for each of the questions. The minor differences were identified, discussed and negotiated until a consensus was achieved (DeSantis & Ugarriza 2000). SPSS 14.0 was used to report the descriptive statistics and aid in the coding processes.
RESULTS A total sample of 56 surveys was returned from an initial survey of 150 overseas nurses (a return rate of 37.3%). The mean age of the group was 24 years with an age range from 21 to 48 years, of these 12.3% were males and 87.7% were female.This sample is significantly younger than the average age of all nurses in NSW, in 2004 it was 39 years (Dorian & Jones 2004). The average length of experience as an RN was reported as 6 years.The average length of time spent in Australia was 9.6 months and typically 6.2 months represent time employed here at the study site.
People travelled to Australia from many different countries, England (n = 27), Canada (n = 6), Scotland (n = 3), Ireland (n = 3), Sweden (n = 3), the United States (n = 2), Zimbabwe (n = 2), China (n = 1), Italy (n = 1), Philippines (n = 1), Fiji (n = 1), Singapore (n = 1), New Zealand (n = 1), Finland (n = 2), South Africa (n = 2). OQNs who spoke English as a first language account for 77.2% (n = 44) of the sample, and 21.1% (n = 12) speak English as a second language. The majority of people live locally (within three kilometres of the hospital) (52%, n = 29), the rest (48%, n = 27) live in other Sydney suburbs. Table 1 contains sample characteristics comparing nurses with an English and Non English speaking background. Nurses with an ESB were more likely to secure employment in their chosen speciality compared with NESB nurses, NESB nurses rated the ward and hospital orientations more positively than nurses with an ESB. Three major themes emerged from the analysis of the open ended questions; career and lifestyle opportunities, differences in practice and homesickness.
TABLE 1: SAMPLE CHARACTERISTICS SEPARATED BY ENGLISH NON -E NGLISH SPEAKING BACKGROUND (NESB)
ESB n = 44 n (%)
NESB n = 12 n (%)
5 (11.4) 39 (88.6) 30 (68) 14 (32) 21 (47.7) 23 (52.3)
2 (16.7) 10 (83.3) 3 (25) 9 (75) 8 (66.7) 4 (33.3)
Mean (SD)
Mean (SD)
24.7 (12.4) 5.6 (2.16) 3.9 (2.44) 5.3 (2.19) 8.7 (11.3) 6.1 (6.03) 6.1 (4.69)
22.7 (14.17) 8.1 (1.74) 6 (2.37) 5.9 (2.74) 12.7 (10.1) 5.3 (3.26) 6.8 (4.34)
Males Females Employed in speciality Not employed in speciality Live Locally Live elsewhere
Age (years) Ward orientation# Hospital orientation# Overall support# Length of time in Australia (months) Length of time as registered nurse (years) Length of time at hospital (months)
SPEAKING BACKGROUND
*P value < 0.05 considered as significant. # Rated on a 10-point Likert scale 1 = not helpful to 10 = most helpful.
104
CN
Volume 28, Issue 1–2, April 2008
(ESB)
VERSUS
P* 0.470 0.026 0.202
0.000 0.000 0.000 0.000 0.000 0.000 0.000
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 105
Expectations and experiences of recently recruited overseas qualified nurses
CN
What many perceive as major differences in practice, are reported as some of the most difficult aspects of work for an OQN. Daniel et al (2001) found that having to be reassessed for their professional competencies created significant frustration and anxiety for OQNs. Dowd, Davidhizar and Newman Giger (1999) argue I would want to gain more knowledge and do the idea of developing tolerance to differences post-graduate courses because I had read that and practising flexibility, as a means of working it is a training/teaching hospital. I was told through the differences in practice. by my lecturers at University that experience in another country would help me go a long Homesickness Homesickness was noted as a problem by a way in my nursing career. number of OQNs.The word ‘homesickness’ and Many of the participants were attracted by the phrases such as ‘missing my family’ and ‘being hospital’s proximity to both the inner city and away from family and friends’ appeared frethe beach, stating that this was the main reason quently in the text. One nurse stated: for their choice of hospital. Many nurses anticiA feeling of home sickness, It is such a pate a vibrant cosmopolitan city, complete with long distance travel required to see family/ a busy and exciting social life. Others are more friends. Not having the support of my immecaptivated by the prospects of warm weather, diate family members is hard, it gives you a relaxed beachside living and friendly people. feeling of despair at times, worry. Some respondents believed that the hospital would be similar to those they had worked in The idea of homesickness has been reported in New Zealand, Canada or the United Kingdom. the literature as a major source of stress for Many expected a large teaching hospital, offer- migrant workers (Verschur, Eurelings-Bontekoe ing good educational opportunities, progressive & Spinhoven 2004; Stroebe,Van Vilet; Hewstone nursing practice, modern facilities and friendly, & Willis 2002). Symptoms of homesickness may relaxed and less hierarchical hospital atmos- include symptoms such as: physical (sleep disphere. Others look forward to having positive turbance, headache, fatigue, gastrointestinal new experiences and embracing fresh chal- complaints), cognitive (negative thoughts about lenges and change in their lives. home, environment, absent mindedness), behavioural (apathy, listlessness, lack of initiative, little interest in new environment) and emotional Differences in practice When comparing differences between OQNs (depressive mood, insecurity, loss of control, hospital of origin and the hospital study site, nervousness, loneliness) (Van Tilburg, Vingernurses made comparisons by describing the dif- hoets & Van Heck 1996). ference they experienced in work practices. DISCUSSION At home, taking bloods and cannulation The majority of OQNs arrived from the UK. comes with the work. Feels ridiculous that The ease of the nurse registration process you have to be assessed to do something you between Australia and the UK, shared language, do every day at home.The medication names culture and history may aid in the adjustment are different, the system is different, and it process for UK OQNs. Difficulties in adjusting can be frustrating at times. to new cultures due to language barriers have
Career and lifestyle opportunities OQNs responses showed that they focused on career and lifestyle opportunities when making decisions about nursing overseas. The teaching hospital status of the study site was an attraction to several nurses. One the comments regarding the importance of having a career focus were:
Volume 28, Issue 1–2, April 2008
CN
105
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 106
Scott Brunero, Julie Smith and Emma Bates
been articulated consistently in the OQN nursing literature (Omeri 2006; Omeri & Atkins 2002; Alexis 2002). Two previously published studies of OQNs (Omeri & Atkins 2002; Jackson 1996) both in New South Wales, Australia, report similar findings to our study. Jackson (1996) reports of being a woman, being stressed, being a stranger, being lonely and being a nurse, Jackson (1996) goes onto report how OQNs sought comfort and a need to establish themselves during their adjustment phase into Australia. Omeri and Atkins (2002) reports on the lived experience of five immigrant nurses in New South Wales. Omeri and Atkins (2002) through naturalistic open ended interviews, found the following emergent themes; professional negation, lack of support, otherness, cultural separateness, silencing, language and communication difficulties in the OQN’s experiences. Omeri and Atkins (2002) demonstrate the distance between people from dominant and non dominant cultures, similar to the reported findings in our study. Nurses from a NESB were less likely to be employed in their chosen speciality than ESB nurses.Whilst we did not ask for direct reasons why this may have occurred, the ability of the individual nurse to communicate their wishes in this area may be a factor. Communication problems for NESB nurses have been noted by several authors (Jeon & Chatterworth 2007; Omeri 2006; Omeri & Atkins 2002; Alexis 2002). Hawthorne (2001) postulates that NESB nurses because of communication problems, have more difficulty with registration procedures and qualification recognition leading to a more lengthy migration process. Communication problems have been further highlighted by Brown (2005) who describes the ‘Yes Syndrome’ in a study of NESB student nurses. Brown (2005) suggests that many cultural groups use the ‘Yes Syndrome’ when people typically answer ‘yes’ to a question, but mean something different. By saying ‘yes’ to questions, the person is able to avoid the embarrass106
CN
Volume 28, Issue 1–2, April 2008
ment of not being understood and having to repeat himself or herself in front of people from the dominant culture. As mentioned previously, our study showed that NESB nurses rated more positively their level of satisfaction with the general hospital and ward orientation, compared to ESB nurses. The specific ward orientation was described as a more rewarding experience.These are generally conducted as one on one session with a nurse educator. It may be that these occasions provide greater opportunities for NESB nurses to clarify meaning and to feel less intimidated about asking questions. The fear of making language and cultural mistakes may also be lessened. The first theme identified was career and lifestyle opportunities. OQNs described career and lifestyle goals as the main motivating factor for immigrating. Kline (2003) examines the reasons why nurses migrate, concluding that nurses migrate because they are seeking better conditions and wages. Daniel et al (2001) reports similar reasons for nurses migrating from the Philippines to the UK, they were career prospects and financial security. Much of the literature focuses on the OQN migrating from developing countries to developed countries. There is less exploration around the reason for migration from developed to developed countries.Where as OQNs from developing nations have financial motives for migrating to developed countries (Hawthorne 2001; Daniels et al 2001). Some evidence for this perception is supported by Connell and Brown’s (2004) study of Tongan and Samoan nurses. Connell and Brown (2004) found that Tongan and Samoan nurses were significantly more involved in sending remittances to their home countries in comparison with other migrant nurse groups. The effects of the pressure and obligation of sending money earned in Australia back to family overseas were not explored in this study. Exploring reasons for OQNs migration may impact on the development of adaptation programmes. Differences in practice were noted by most
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 107
Expectations and experiences of recently recruited overseas qualified nurses
CN
OQNs. OQNs gave a range of clear descriptions of differences in nursing practice. The notion of examining differences in practice has been captured by Pillette (1989). Pilette (1989) describes a phase of adjustment called the ‘Indignation Phase’.This period is characterised by cultural, professional and psychological dissonance. It is described as an intense period of emotion and ambiguity and typically occurs six and nine months post arrival.The OQNs in this study had been here on average 6.2 months, their comments provide a measure of support for the notion of ‘professional dissonance’ as an adjustment issue. Organisations that can articulate the observed differences in practice may be able to design better assimilation programmes. The effect of not observing differences in practice may lead to negative outcomes for the OQN and patient. In support of this, Blackford and Street (2000) study of 26 nurses found that NESB nurses learned to ignore their own traditions and practices in the dominant AngloAustralian culture. Homesickness was reported by many of the OQNs. Whilst not described as a formal psychiatric disorder, homesickness is reported as being a potential distressing state of anxiety and depressive type symptoms (Van Tilburg et al 1996). Personality types and environmental characteristics play an important part in the role and onset of homesickness. The severity and consequences of prolonged homesickness is unclear in the literature, but there are arguments for its management and monitoring, as it has been anecdotally linked to depression and anxiety symptoms in migrants (Van Tilburg et al 1996). Using the literature and the study results interventions have been designed to address the difficult issues faced by OQNs during their adjustment phase. An organisational and a personal approach have been utilised.
organisation that values diversity is key in assisting the OQN through their adjustment phase (Bruhn 1996). Alexis and Chambers (2003) make a case for the need of an organisational approach in helping with the adjustment of OQNs. Key elements include the notion of open participation, the encouragement of feedback and existence of control at lower levels of the organisation. At the study site these attitudes and behaviours are reflected in the development of transformational leaders, person centeredness and the growth of a practice development model of nursing care, which encompasses the central philosophies of shared governance, open participation, participatory evaluation and emancipation or developing of the self (McCormack 2005). These practice changes reflect well with recommendations from Bruhn (1996), Alexis and Chambers (2003) and Davidhizar et al (1999) valuing diversity, sharing beliefs and decision-making. To further create and encourage the valuing of diversity, an electronic book style orientation manual for OQNs has been developed and produced as a web-based resource named ‘Signpost’. After careful review of the literature and the data from this study, Signpost was created. Key principles in writing the manual were ease of reading and accessibility. Due to the age group of the nurses, it was decided to present the information primarily in an electronic based format, to allow for widespread accessibility in Australia.The study population were primarily Y generation nurses who are broadly described from a western perspective as the Internet generation (Martin 2001).The suggestion from this author is that this generation responds to immediate feedback, clear expectations from employers and have clear career goals. For this reason an electronic format has been chosen for the orientation manual. In a review of health information on the Internet, Berland, Elliot and Morales (2001) found that the information was easily accessible and reasonable, although they Organisational interventions It has been argued that the development of an did report the readability level as too high.
Volume 28, Issue 1–2, April 2008
CN
107
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 108
Scott Brunero, Julie Smith and Emma Bates
Bridges and Thede (1996) explain that for nurses who use the Internet, it offers a rich source of accessible material, with the challenge being in the critiquing of the contents. In a series of virtual focus groups with nurses, Dickerson and Feitshans (2003) found that nurses see the Internet as a source of communication, and a resource that’s appealing and entertaining, they also report that nurses found it frustrating at times, having to learn new rules and systems. Readability level is a key issue in presenting information and for the orientation manual it was kept between 11th and 14th grade using Flesch readability statistics (Davis et al 1990). Signpost was divided into the following sections: an introduction to the electronic book, background, orientation and settling in information, nursing practice model, nursing registration, role definitions, professional nursing organisation, general living, schools, transport, accommodation, staying connected, support, how to phone home, and a frequently asked questions section. The creation of an organisation that respects cultural and linguistically diverse groups is essential in helping the OQN to successfully adjust to their new working environment. In an effort to educate the dominant culture at the study site the hospitals newsletter is being used to tell an OQN narrative, using the transcultural assessment model as described by Dowd et al (1999). The narrative will contain the expectations, experiences, communication, environmental and social issues of the OQNs experience. The aim of these narratives is to influence the dominant culture and develop their understanding of the OQN workforce at the hospital.
Personal approaches Dowd et al (1999) describes a transcultural model of assessment that could be used by OQNs to assist them on their arrival to their destination country. At the study site this is offered in a group or individual setting, OQNs 108
CN
Volume 28, Issue 1–2, April 2008
are given a brief overview of the model and are then taken through the self-assessment checklist, as provided by Dowd et al (1999). OQNs that are identified as being distressed, suffering with the physical, cognitive, behavioural or emotional symptoms of homesickness, are given more information on how best to manage these symptoms. Interventions used for homesickness fall within the stress management literature.Van Tilburg et al (1996) review the use of a range of therapies, from expression of feelings, cognitive behavioural therapy (CBT), regular telephone calls home, and assertiveness training. At the study site the use of CBT interventions (for example, challenging negative thoughts that lead to high levels of anxiety and depression) is offered, (Ellis 1957; Ellis & Grieger 1986), through one to one sessions or via a self directed reading booklet (Brunero et al 2006). Using a CBT framework the authors have focused on working with the expectations OQNs have of their destination workplace.The use of this approach has been linked to future reports of job satisfaction (Wanous et al 1992). Capturing a sense of the dichotomy between people’s expectations and actual experience may help individuals in the adjustment process. A process of assessing the accuracy of individual’s expectations before they engage in the actual experience may help shape the views on their work satisfaction levels. At a practical level this may simply mean asking new recruits to list their expectations, how they view their work and lifestyle, and what it’s like being in the destination workplace. Individuals then engage with someone from the destination (eg recruitment officer) who can affirm the accuracy of their expectations, and alleviate any misconception and emotional distress (such as anxiety, depression and anger) that a person may have developed before or during their employment. This process has been named as ‘expectation affirmation’ and has been developed into a questionnaire style template (available from the authors).
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 109
Expectations and experiences of recently recruited overseas qualified nurses
CONCLUSIONS The organisational and personal interventions will require ongoing evaluations. A proposal to have a OQNs support role is being developed. The intention of the role would be to broaden the delivery and evaluation of the interventions. Offering the ‘missing’ information and interventions at the recruitment and arrival stages, may encourage nurses to feel more confident and better equipped to settle into Australian life. Interventions designed to provide OQNs a warm welcome and an introduction to living and working in this locale may also help them feel that they are an essential and important part of this organisation.
Acknowledgment This study was partly funded by a NSW Department of Health Nursing Innovations Scholarship. References Alexis O (2002) Diversity and equality recruiting and retaining overseas ethnic minority nurses in the NHS, Nursing Management 9: 22–26. Alexis O and Chambers C (2003) Exploring Alexis’ model: Part two valuing resources, Nursing Management 10: 22–25. Berland G, Elliot M, and Morales L (2001) Health information on the Internet, The Journal of the American Medical Association 285: 2615–2621. Blackford J and Street A (2000) Nurses of NESB working in a multicultural community, Contemporary Nurse 9(1): 89–98. Bridges A and Thede L (1996) Nursing education on the world wide web, Nurse Educator 21: 11–15. Brown V (2005) Culturally and Linguistically Diverse Nursing Student Education: A Grounded Theory Study. PhD Thesis, Curtin University of Technology,Western Australia. Bruhn J (1996) Creating an organisational climate for multiculturalism, The Health Care Supervisor 14: 11–18.
CN
Brunero S, Cowan D, Grochulski A and Garvey A (2006) Stress Management for Nurses, accessed at http://www.nswnurses.asn.au/info pages/5696.html on 22nd November 2007. Connell J and Brown R (2004) The remittances of migrant Tongan and Samoan nurses from Australia, Human Resources for Health 2: 1–21. Daniel P and Chamberlain G (2001) Expectations and experiences of newly recruited Filipino nurses, British Journal of Nursing 10: 254–265. Davidhizar R, Dowd S and Newman Giger J (1999) Managing diversity in the health care workplace, The Health Care Supervisor 17: 51–62. Davis T, Crouch M,Wills G, Miller S and Abdehou D (1990) The gap between patient reading comprehension and the readability of patient education materials, Journal of Family Practice 31: 533–538. DeSantis L and Ugarriza D (2000) The concept of theme as used in qualitative nursing research, Western Journal of Nursing Research 22: 351–372. Dickerson S and Feitshans L (2003) Internet users becoming immersed in the virtual world: implications for nurses, Computers, Informatics, Nursing 21: 300–308. Dowd S, Davidhizar R and Newman Giger J (1999) Will you fit if you move to a job in another culture, The Health Care Manager 18: 20–27. Dorian D and Jones G (2004) Nurses retention and hospital characteristics in New South Wales, accessed at www.econ.mq.edu.au /seminars/ER.pdf on 22 January 2007. Ellis A (1957) Rational psychotherapy and Individual psychology, Journal of Individual Psychology 13: 38–44. Ellis A and Grieger R (1986) Handbook of Rational Emotive Therapy,Vol 2, Springer, New York. Gerrish K and Griffith V (2003) Integration of overseas Registered Nurses: evaluation of an adaptation programme, Nursing and Health Care Management and Policy 45: 579–587. Hawthorne L (2001) The globalisation of the nursing workforce: barriers confronting
Volume 28, Issue 1–2, April 2008
CN
109
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 110
Scott Brunero, Julie Smith and Emma Bates
overseas qualified nurses in Australia, Nursing Inquiry 8: 213–229. Hawthorne L,Toth J and Hawthorne G (2000) Patient demand for bilingual bicultural nurses in australia, Journal of Intercultural Studies 21: 193–224. ICN (2007) International Council of Nurses. Ethical Nurse Recruitment position statement. Accessed at http://www.icn.ch/psrec ruit01.htm#_ftn1 on 22 November 2007. Jackson D (1996) The multicultural workplace: comfort, safety and migrant nurses, Contemporary Nurse 5: 120–126. Jeon Y and Chenoweth L (2007) Working with culturally and linguistically diverse (CALD) group of nurses, Collegian 14: 16–23. Kline D (2003) Push and Pull factors in International Nurse Migration, Journal of Nursing Scholarship 35: 107–111. Konno R (2006) Support for overseas qualified nurses in adjusting to Australian nursing practice: a systematic review, International Journal of Evidence Based Healthcare 4: 83–100. Martin C (2001) Managing Generation Y, HRD press, Massachusetts. McCormak B, Manley, K and Garbett R (2004) Practice Development in Nursing, 3rd edn, Blackwell, London. Omeri A and Atkins K (2002) Lived experiences of immigrant nurses in New South Wales,
P O S T
Australia: Searching for meaning, International Journal of Nursing Studies 39: 495–505. Omeri A (2006) Workplace practices with mental health implications on recruitment and retention and retention of overseas nurses in the context of nursing shortages, Contemporary Nurse 21(1): 50–61. Oxtoby K (2003) The Overseas Nurses Champion, Nursing Times 99: 42–43. Pilette P (1989) Recruitment and retention of international nurses aided by recognition of phases of the adjustment process, The Journal of Continuing Education in Nursing 20: 277–281. Ryan M (2003) A buddy program for international nurses, JONA 33: 350–352. Stroebe M,Van Vilet T, Hewstone M and Willis H (2002) Homesickness among students in two cultures: antecedents and consequences, British Journal of Psychology 93: 147–168. Van Tilburg M,Vingerhoets A and Van Heck G (1996) Homesickness: A review of the literature, Psychological Medicine 26: 899–912. Verschuur M, Eurelings-Bontekoe E and Spinhoven P (2004) Associations among homesickness, anger, anxiety, and depression, Psychological Reports 94: 1155–1170. Wanous J, Poland T, Premack S and Davis K (1992) The effects of met expectations on newcomer attitudes and behaviours: a review and meta-analysis, Journal of Applied Psychology 77: 288–297.
P R E S S E D
A C A D E M I C
S ECOND L ANGUAGE W RITING S TRATEGIES By Congjun Mu ISBN: 978-1921214-06-6; 360 pages; 2007; imprint: Post Pressed That many overseas university students whose first language is not English lack adequate proficiency in formal academic English has become an issue of growing concern. This timely study examines the writing strategies used by three Chinese post-graduate students while writing academic papers in English. Similarities and differences between the L2 and L1 writing processes are explored and a major hindrance to acculturating into the target academic discourse community is found to be a background of reader-responsibility which is regarded as a crucial feature in Eastern rhetoric and is distinguished from writer-responsibility in English rhetoric. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected]; www.e-contentmanagement.com
110
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 111
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 111–118.
A reflection on culture over time by Baccalaureate nursing students ABSTRACT
Key Words culturally competency; nursing students; reflection
The aim of this retrospective descriptive study was to compare students’ reflective responses to a set question 18 months apart to determine if their understanding of nurses’ commitment to serve all clients regardless of age, gender, religious affiliation, or racial origin changed. One hundred and twentysix reflections (63 pairs) were thematically analysed.Three themes were developed: equal treatment; commitment to serve all clients; and ‘it’s not easy’. Cultural competency, although not yet fully operationalized in the nursing profession, is a developmental process that goes across time. It is also more than learning about other cultures. Received 15 July 2007
HENDRIKA J MALTBY Associate Professor Department of Nursing University of Vermont Burlington VT, USA and Adjunct Associate Professor Edith Cowan University Joondalup WA, Australia
I
n the global environment of today’s world, nurses must be educationally prepared to meet the needs of people from culturally and linguistically diverse backgrounds in order to provide high quality care. DeSantis and Lipson (2007) outline the history of the inclusion of cultural content in nursing education, dating from the influences of Florence Nightingale. They summarise the impetus to include cultural content, and outline recent reaffirmations to do so by various jurisdictions such as the American Association of Colleges of Nursing, the Ameri-
Accepted 8 April 2008
CN
can Nurses Association,The Joint Commission, and the National League of Nurses to name a few. The impetus, past and present, includes globalisation, growing diversity in the population, bioethical issues, health disparities, and the need to increase diversity in the nursing workforce. In the United States, the Essentials for Baccalaureate Education (American Association of Colleges of Nursing [AACN] 1998) stipulate that graduates of baccalaureate nursing programs must have the knowledge and skills to care for a diverse population.This entails knowing and understanding how culture, race, socioeconomic status, age, gender, religious, and lifestyle factors affect health and the provision of care (AACN 1998). The Essentials dovetail into the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care (US Department of Health and Human Services, Office of Minority Health [USDHHS, OMH] 2001) which are to provide
Volume 28, Issue 1–2, April 2008
CN
111
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 112
Hendrika J Maltby
care compatible with cultural beliefs and practices in a preferred language.1 The Joint Commission (the accrediting body for healthcare organisations) (2007) uses CLAS to assess whether organisations provide culturally appropriate care in the interest of patient safety and quality of care. The definition used by USDHHS, OMH (2001) for cultural and linguistic competence is: … a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. ‘Culture’ refers to integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.‘Competence’ implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. (USDHHS, OMH 2001: 4)
should be taught, lack of standards, limited formal evaluation, unstated outcome standards, lack of linguistic skill, and the need for faculty qualifications and preparation. Of concern is that integrating cultural concepts into each course tends to be very dependent on interested faculty members related to crowded curricula and preparation to pass the NCLEX-RN (The National Council Licensure Examination, for registered nurses).
OUR PROGRAM Our program is located in a small city in a very Caucasian rural state in Northern New England.There are approximately 375 students in the undergraduate program. Students entering the nursing program spend the first three semesters (one-and-a-half years) completing required courses such as the sciences, psychology/sociology, philosophy, and electives.They are also required to take a three credit American race and racism course (focusing on race, culture and gender relationships in America) during their program (a university wide requirement); most nursing students take this course in their first three semesters. Beginning in the second semester second year (sophomore Spring), students begin the nursing courses which are composed of theory and clinical practice.They must also complete their elective requirements. Faculty ensure that transcultural nursing concepts are integrated throughout the curriculum. This is iterated in our strategic plan as one of the first action steps is to ‘develop, strengthen, and support international and multicultural opportunities for education and research for faculty and students: (e) enhance faculty sensitivity and cultural competencies’. There has been, however, no further discussion on what this might mean or how to measure competencies.
This definition is how culture was understood throughout this project and what had been taught in the health promotion course during the junior fall semester. Despite the stipulation to incorporate cultural knowledge and skills to care for a diverse population in nursing education, Ryan, Carlton and Ali (2000) in their survey of baccalaureate nursing programs, discovered that transcultural nursing concepts were incorporated into most of the curricula, but that ‘wide variation exists as to content, depth, and level of integration’ (Ryan, Carlton & Ali 2000: 300). Only 2.3% (89 of 205 reporting) of these programs had formal courses in transcultural nursing. Boyle (2000), Campinha-Bacote (2006), and Lipson AIM and DeSantis (2007) also questioned the depth The current study arose out of my need to of cultural content in nursing curricula. These determine if integrating cultural content (as researchers cite a lack of consensus on what determined by individual faculty) in nursing 112
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 113
A reflection on culture over time by Baccalaureate nursing students courses affected students’ understanding of culturally appropriate care. Therefore, the aim of this retrospective, descriptive study was to thematically analyse and compare students’ reflective responses between two points in time to determine if their understanding of professional nurses’ commitment to serve all clients (client is defined as individuals, families, groups, communities) regardless of age, gender, religious affiliation, or racial origin changed between the junior fall (first semester third year) and senior spring (second semester fourth year). Did their understanding of cultural aspects of care change over the length of the nursing program? Were they able to provide examples of how culture affected nursing care.
METHODOLOGY Using a convenience sample, 85 junior nursing students were given an in-class reflection question to complete during an October class period (Time 1, T-1) as part of their course requirements.The same reflection question was answered by the same students 18 months later prior to graduation (Time 2, T-2). Submission during their final semester was not required to pass the course. Although names were attached to the responses, once the responses were matched, the names were deleted.The two sets of responses were matched and those students who had completed just one reflection at either time period were deleted. A total of 126 reflections were analysed (63 pairs). Institutional Review Board approval was obtained for the study. Students could indicate that they did not want their responses included in the study although no-one chose this option.The question was: Nurses’ commitment to serve all clients regardless of age, gender, religious affiliation, or racial origin is an essential component of the ANA Code of Ethics.Why is this commitment essential in nursing practice? How
CN
would/did you implement it in your nursing practice? Responses were thematically analysed by the author using the steps outlined by Colaizzi (1978): reading all the descriptive data, extracting significant themes, formulating meanings, clustering meanings, writing an exhaustive description, and identifying the basic structure of the concepts. The final step, seeking validation by returning to the participants, could not be implemented as students had graduated and were lost to follow-up. A second nursing colleague audited the themes and, in her experience, found them credible and based on the collected data.
LIMITATIONS This was a small study at one school, however it had the advantage of assessing students over time.The reflection question itself may have led students to answer in a particular manner. As well, validation by the students was not possible.
RESULTS A total of 63 out of a possible 85 student responses (126 reflections) were included in the study.The final response rate was 74%.The participants in this study are overwhelmingly white (non-Hispanic) (100%) and female (95%).This is similar to the American registered nurse population where 82% are estimated to be white (non-Hispanic) and 5.7% were men (Health Resources & Services Administration 2004). Ages ranged from 20 to 47 years. Three main themes emerged from the data: ‘equal treatment’, ‘commitment to serve all clients’, and ‘it’s not easy’.
Equal treatment One of the main themes from the analysis of the responses is that students would treat patients equally. Comments included: ‘Implementing equal care to all is essential in my practice’ (5,T2); ‘I implemented this in my practice by treatVolume 28, Issue 1–2, April 2008
CN
113
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 114
Hendrika J Maltby
ing all patients equally and not letting my personal opinions and beliefs get in the way of patient care’ (17, T-2); ‘Regardless of gender, orientation, race, or religion they are humans and deserve equal treatment’ (19,T-1); ‘I would treat all my patients equally’ (30, T-1); ‘all clients deserve to be treated equally regardless of their gender, age, racial origin, or religious affiliation’ (62,T-2); and ‘I implemented this in my practice by treating all patients equally and not letting my personal opinions and beliefs get in the way of patient care’ (18,T-2). Students at both time periods were very aware that bias in nursing care was unacceptable and could lead to poor quality care.This was even more evident at T-2 after students had been in several clinical rotations: ‘I make it a point to spend the needed amount of time with each of my patients and not neglect one, just because they are ‘not the same as me’. I prioritise based on the needed events not the patient’s beliefs or background’ (33, T-2). A few students did state that ‘every individual deserves equal respect’, which is fundamental, but added ‘and treatment’ (35, T-2). The following student stated that patient characteristics did not affect the care but did try to provide culturally competent care, indicating some confusion between equal and equality: I cared for patients of various ages, both male and female, from many religious affiliations and many different racial origins. These characteristics did not affect my care of my patients at all. I did however try to give culturally competent care and ask my patients if there were any cultural or religious beliefs that would change their care. (58,T-2) Treating clients/patients ‘equally’, while a noble sentiment, seems at odds with implementing care that is culturally appropriate as one would not treat each patient equally but according to needs.The concept of equal treatment versus equitable treatment needs further discussion in the classroom as does the meaning 114
CN
Volume 28, Issue 1–2, April 2008
of culturally sensitive and competent care. Similarly, Browne et al (2002) found that nurses in their study would make an effort to treat all patients equally, which ‘assumes that treating people the same way results in equality of care’ (p. 26). As Browne and Varcoe (2006) point out, cultural sensitivity is an important concept and must be viewed from a broad perspective that takes into account the power relationships in nurse/patient interactions. Becoming aware of our own power, knowledge, and privilege as nurses needs to be encouraged (Browne et al 2002) and may lead to care that is equitable for patients.
Commitment to serve all clients Another theme was that the commitment to serve all clients was essential as it is part of being a nurse and led to quality care. Student 4 stated ‘If you have personal biases against a certain client then you may jeopardise their quality of care’ (T-1). Another student stated ‘When you choose to be a part of the [nursing] profession you are accepting the challenge of providing care regardless of their religious affiliation, race, etc.’ (13, T-2). Other students comments were in a similar vein: ‘It’s up to the nurse to put their biases aside and recognise the value of multicultural experiences in their practice’ (59, T-1); ‘I can’t imagine wanting to be a nurse and not being willing to care for any patient regardless of age, gender, religious affiliation, or racial origin’ (43, T-2); ‘Even though I may disagree [with different life situations and different beliefs], I wouldn’t show that or voice my own opinion’ (14,T-1); and ‘Nursing and health care should be completely blind to biases’ (23,T-1). Students at T-1 were more willing to state that they needed more knowledge about cultures in order to understand the patients and their needs. As well, they were more willing to ask the patients the questions to find out the information. The increase time in clinical practice was evident at T-2 as students could speak from some experience about putting culturally
CNJ 28_1_2_internal.qxd
14/07/2008
12:27 PM
Page 115
A reflection on culture over time by Baccalaureate nursing students appropriate care into action but very few gave specific examples. The commitment to serve all clients is very clear for these students at T-1 and T-2.They are also in the process of becoming ‘nurses’ and, despite the hours in clinical, have little experience of testing this commitment. Similar to a study by Chalmers, Sequire and Brown (2003: 9) who stated ‘nursing students also believed practitioners must be nonjudgmental in all situations’, the students in our program espoused the belief that being nonjudgmental and nonbiased was an essential trait for nurses.
It’s not easy A final theme that came from the students’ responses was that it is not always easy to accept a patient’s viewpoint. Most of these are from T2 after they had clinical experiences and were no longer speaking hypothetically. Students provided the following statements: ‘I would question why a 49-year-old woman would want to go through a pregnancy because of the complications associated with their age’ (14, T-2); ‘Even though I may have thought to myself, ‘Wow, this person is a waste of my time!’, I wasn’t completely deterred [from educating them about quit smoking]’ (28, T-2); ‘When I was in clinical I realised how I felt about young moms and moms who smoke. I did not change my practice of care towards them’ (48,T-1); and ‘A nurse may find him or herself passing judgments about a teenage girl that is in the hospital for prenatal care who is still smoking cigarettes’ (53,T-2). Students were quite honest in their feelings about certain patients.This particular theme fit very closely with the previous one on commitment and not being judgemental. Students were finding out that not being judgemental was not easy. Campinha-Bacote’s (1999, 2002a, 2002b) model, The Process of Cultural Competence in the Delivery of Health Care Services, can be used as a framework for exploration and reflection in practice. She defines cultural competence as
CN
‘the ongoing process in which the health care provider continuously strives to achieve the ability to effectively work within the cultural context of the client (individual, family, community)’ (2002a: 181). There are five constructs that comprise the model. Cultural awareness is examining one’s own biases and culture; cultural knowledge seeks to learn about different cultural and ethnic groups; cultural skill is the ability to conduct a cultural assessment; cultural encounter encourages face-to-face interactions with culturally diverse clients; and cultural desire is the motivation to engage in the process of cultural competence. Campinha-Bacote (2002b) has depicted her model as a volcano: when cultural desire erupts, the health care provider will genuinely seek cultural encounters, obtain cultural knowledge, conduct culturally sensitive assessments, and be humble to the process of cultural awareness. Use of cultural awareness assessment tools (Flowers 2004) may also be useful to begin discussions about biases and judgments that can lead to discriminatory practices.
DISCUSSION The definition of culture and cultural competence has been examined and deconstructed by various authors including Kirkham et al (2002) and Browne and Varcoe (2006). These authors describe culture as complex and provide a historical context of the meaning of culture.They focus on previous views of culture as being ‘fixed or static’ (2006: 158). As well, those that are considered different from ‘us’, are considered as ‘other’. While the definition provided by USDHHS, OMH is not explicit regarding the ‘fixed’ nature of culture, it does have the element of ‘other’, rather than the inclusiveness that is necessary. American Institutes for Research report (2002: 8) build on the definition of culture that encompasses the complexity of the concept: ‘ethnicity and social status are inextricably linked, and social issues such as stereotyping, institutionalised racism, and dominant-group privilege are as real in the examin-
Volume 28, Issue 1–2, April 2008
CN
115
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:27 PM
Page 116
Hendrika J Maltby
ing room as they are in society at large’. Kirkham and Anderson (2002: 4) state that ‘culture is commonly understood as a template or blueprint for human behavior, grounded in the values, beliefs, norms, and practices of a particular group that are learned and shared’. It must, however, be seen in context within ‘historical, social, economic, and political relationships and processes’ (Anderson & Kirkham 1999, cited by Browne & Varcoe 2006: 162). Beal (2005: 7) suggests that the ‘specific competencies for delivering culturally competent care have not yet been fully articulated’ but feels that it does contribute to patient outcomes. There are a variety of teaching techniques that can be used to engage students in the process of becoming culturally competent such as role play (Shearer & Davidhiza 2003), using exemplars from literary journalism (Anderson 2004), and using web-based interactions (Kennell, Nyback & Ingalsbe 2005). Also, different experiences such as with the homeless (Hunt & Swiggum 2007), immigrant groups (Moch et al 1999;Warner 2002), and rural populations (Thomas et al 2003) can be included in the curriculum. Exchanges, faculty led programs abroad, and immersion experiences are also invaluable in helping students expand their knowledge and cultural competency (Duffy 2001; Hoffmann et al 2005; Ryan & Twibell 2002). Barnes (2004) provides a very detailed list and explanation of various strategies that can be implemented to influence cultural engagement of students and practicing nurses.
CONCLUSION It would be impossible for nurses to have a working knowledge of all cultures. They can, however, be aware of the role of culture (in its broadest sense) in providing care. Cultural competency, although not yet fully operationalised in the nursing education, is a developmental process that goes across time. There also needs to be a focus on outcome criteria (Boyle 2000; Campinha-Bacote 2006; Gilbert 2002) for grad116
CN
Volume 28, Issue 1–2, April 2008
uating students related to the provision of culturally competent nursing care. Cultural competency needs to be implicit and explicit in our nursing education programs not only to enhance quality client care but also to advance nursing as a profession. The more time that I have spent in clinical rotations, the more interactions I have had with clients and I realize now the importance of religion, culture and other practices on a client’s wellbeing. Nursing is not only about giving medications and getting clients ready for procedures; it is about building interactions and relationships with clients. Relationships cannot be formed if there are hidden judgments or ignorance from the nurse about a particular client. (25,T-2)
Acknowledgments Thank you to the students who were involved in this study.You have taught me as well. Endnote 1 All 14 CLAS Standards are listed at: http: //www.omhrc.gov/templates/browse.aspx? lvl=2&lvlID=15 References American Association of Colleges of Nursing (1998) The essentials of baccalaureate education. Washington, DC. American Institutes for Research (2002) Teaching Cultural Competence in Health Care:A review of current concepts, policies and practices. Report prepared for the Office of Minority Health, Washington, DC. Anderson KL (2004) Teaching cultural competence using an exemplar from literary journalism. Journal of Nursing Education 43: 253–259. Barnes LL (2004) Concept Paper: Culturally competent care. Commissioned for the Consensus Building Meeting for the Culturally competent Nursing Modules project, Office of Minority Health.Washington, DC: American Institutes for Research. Beal G (2005) Knowledge and action: Developing
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 117
A reflection on culture over time by Baccalaureate nursing students cultural competence. Journal of Psychosocial Nursing and Mental Health Services 43: 7. Bloomberg School of Public Health, Center for Communication Programs (2002) Questionnaire for Values Clarification. Johns Hopkins. Boyle JS (2000) Transcultural nursing:Where do we go from here? Journal of Transcultural Nursing 11: 10–11. Browne AJ and Varcoe C (2006) Critical cultural perspectives and health care involving Aboriginal peoples. Contemporary Nurse 22: 155–167. Browne AJ, Johnson JL, Bottorff JL, Grewal S and Hilton BA (2002) Recognizing discrimination in nursing practice. Canadian Nurse 98: 24–27. Campinha-Bacote J (1999) A model and instrument for addressing cultural competence in health care. Journal of Nursing Education 38: 203–207. Campinha-Bacote J (2002a) The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing 13: 181–184. Campinha-Bacote J (2002b) A culturally consciously model of care, accessed at http://www .transculturalcare.net/Cultural_Competence_ Model.htm Campinha-Bacote J (2006) Cultural competence in nursing curricula: How are we doing 20 years later? Journal of Nursing Education 45: 243–244. Chalmers K, Sequire M and Brown J (2003) Health promotion and tobacco control: Student nurses’ perspectives. Journal of Nursing Education 42: 106–112. Colaizzi P (1978) Psychological research as the phenomenologists view it, in Valle R & King M (Eds) Existential-Phenomenological Alternatives for Psychology, Oxford University Press, New York. DeSantis LA and Lipson JG (2007. Brief history of inclusion of content on culture in nursing education. Journal of Transcultural Nursing 18: 7S–9S. Duffy ME (2001) A critique of cultural education in nursing. Journal of Advanced Nursing 36: 487–495. Flowers DL (2004) Culturally competent nursing care: A challenge for the 21st century. Critical Care Nurse 24: 48–52. Gilbert MJ (Ed.) (2002) Principles and Recommended Standards for Cultural Competence Educa-
CN
tion of Health Care Professionals.The California Endowment, Los Angeles CA. Health Resources & Services Administration (2004) Preliminary Findings: 2004 National Sample Survey of Registered Nurses.Washington, DC: US Department of Health and Human Services, accessed at http://bhpr.hrsa.gov /healthworkforce/reports/rnpopulation/ preliminaryfindings.htm Hoffmann RL, Mesmer PR, Hill-Rodriguez DL and Vazquez D (2005) A collaborative approach to expand clinical experiences and cultural awareness among undergraduate nursing students. Journal of Professional Nursing 21: 240–243. Hunt RJ and Swiggum P (2007) Being in another world:Transcultural student experiences using service learning with families who are homeless. Journal of Transcultural Nursing 18: 167–174. Jeffreys MR (2000) Development and psychometric evaluation of the transcultural selfefficacy tool: A synthesis of findings. Journal of Transcultural Nursing 11: 127–136. Joint Commission (2007) Hospital, language and culture, accessed at http://www.jointcommis sion.org/PatientSafety/HLC/ Kennell LS, Nyback MH and Ingalsbe KS (2005) Increasing cultural competence through asynchronous web-based interactions between two nursing programs. Journal of Nursing Education 44: 244. Kirkham SR and Anderson JM (2002) Postcolonial nursing scholarship: From epistemology to method. Advances in Nursing Science 25: 1–17. Kirkham SR, Smye V,Tang S, Anderson J, Blue C and Browne A (2002) Rethinking cultural safety while waiting to do fieldwork: Methodological implications for nursing research. Research in Nursing and Health 25: 222–232. Lipson JG and Desanti, LA (2007) Current approaches to integrating elements of cultural competence in nursing education. Journal of Transcultural Nursing Supp 18: 10S–20S. Moch SD, Long GL, Jones JW, Shadick K and Solheim K (1999) Faculty and student crosscultural learning through teaching health promotion in the community. Journal of Nursing Education 38: 238–240. Office of Minority Health, US Department of Health and Human Services (2000) National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care.
Volume 28, Issue 1–2, April 2008
CN
117
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 118
Hendrika J Maltby
Federal Register, 65(247): 80865–80879. Rockville, MD. Preacher KJ (2001) Calculation for the chi-square test: An interactive calculation tool for chisquare tests of goodness of fit and independence, accessed at http://www.psych.ku.edu /preacher/chisq/chisq.htm Rew L, Becker H, Cookston J, Khosropour S and Martinez S (2003) Measuring cultural awareness in nursing students. Journal of Nursing Education 42: 249–257. Ryan M & Twibell RS (2002) Outcomes of a transcultural nursing immersion experience. Journal of Transcultural Nursing 13: 30–39. Ryan M, Carlton K and Ali N (2000) Transcultural nursing concepts and experiences in nursing curricula. Journal of Transcultural Nursing 11: 300–307.
Shearer R and Davidhizar R (2003) Using role play to develop cultural competence. Journal of Nursing Education 42: 273–276. Thomas MD, Olivares SA, Kim HJ & Beilke C (2003) An intensive cultural experience in a rural area. Journal of Professional Nursing 19:126–133. US Department of Health and Human Services, Office of Minority Health (2001) National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Rockville MD: Author. Available from: http:// www.omhrc.gov/assets/pdf/checked/final report.pdf Warner JR (2002) Cultural competence immersion experiences. Public health among the Navajo. Nurse Educator 27: 187–190.
** NOW AVAILABLE **
U SING Q UALITATIVE AND Q UANTITATIVE M ETHODS IN D EVELOPMENT P OLICY Q-squared Decision Making in the Case of Poverty Analysis Edited by Paul Shaffer (University of Toronto), Ravi Kanbur (Cornell University), Ellen Bortei-Doku Aryeetey (University of Ghana) and Nguyen Thang (Vietnam Academy of Social Sciences) A special issue of International Journal of Multiple Research Approaches, volume 2 issue 2 ISBN 978-1-9213482-6-6; iv + 92 pages; s/c; October 2008 • Editorial — Ravi Kanbur, Paul Shaffer, Nguyen Thang, Ellen Bortei-Doku Aryeetey • Combining Survey and Ethnographic Methods to Improve Evaluation of Conditional Cash Transfer — Michelle Adato • Poverty Dynamics and Life Trajectories in Rural Bangladesh — Bob Baulch, Peter Davis • On Trying to be Q2: Merging Methods for a Technical Minded Client — Nilakshi de Silva, Gunetilleke Neranjana • Resolving Conflicting Evidence on ‘GMOs’ in Rural India: The Warangal Method — Ronald J Herring • Trade Liberalisation and Childhood Poverty in Vietnam: A Q2 Social Impact Analysis — Nicola Jones, Ngoc Anh Nguyen, Thu Hang Nguyen
• The Balance of All Things: Explaining Household Poverty Dynamics in 50 Villages of Gujarat, India — Anirudh Krishna, J Daniel Lecy • Combining Quantitative and Qualitative Research to Further Our Understanding of Poverty Dynamics: Some Methodological Considerations — David Lawson, David Hulme, James Muwonge • Combined Methods in Poverty Analysis: Experiences from Namibia — Sebastian Levine, Benjamin Roberts • Community-based Change Ranking to Assess the Impact of a Programme for the Ultra Poor — Munshi Sulaiman, Imran Matin
Course Coordinators are invited to contact the Publisher for an adoption evaluation copy. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
118
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 119
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 119–128.
Integrative simulation: A novel approach to educating culturally competent nurses ABSTRACT
Key Words transcultural nursing; culture; cultural competency; simulation; cultural diversity; nursing education
Nursing education faces many challenges as a result of the population’s increased cultural diversification. Of primary importance is the need to prepare culturally competent nurses to provide care in both urban and remote rural areas.This paper presents a HRSA funded program that utilises simulations to provide culturally diverse learning opportunities for both university-based and distance learning students. Cases are developed using focus groups and individual interviews.The information is used with standardised patients to develop vignettes that are loaded into a web-based virtual hospital where students conduct interviews with culturally diverse patients.The information obtained during the interview is then used to provide hands-on care to a high performance simulator (simulated mannequin).The encounters are videotaped for use in debriefing sessions with the students, for educational programs in the classroom, and for video-streaming to web-based distance students. Students in the debriefing sessions and classroom participate in a review of the videotape using the Personal Response System to respond to question. Through the culturally enhanced integrated simulation, students have an opportunity to address clinical situations and the impact of culture in a relatively safe nonthreatening environment where the impact of their biases can be explored. Received 14 July 2007
Accepted 9 April 2008
CN
CAROLYN M RUTLEDGE
PHYLLIS BARHAM
School of Nursing Old Dominion University Norfolk VA, USA
School of Nursing Old Dominion University Norfolk VA, USA
LYNN WILES
RICHARDEAN S BENJAMIN
School of Nursing Old Dominion University Norfolk VA, USA
School of Nursing Old Dominion University Norfolk VA, USA
Authors continued/ ...
Volume 28, Issue 1–2, April 2008
CN
119
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 120
Carolyn M Rutledge et al PHYLLIS EATON School of Nursing Old Dominion University Norfolk VA, USA
INTRODUCTION
H
ealthcare is facing a number of challenges. First and foremost is the need to provide care to culturally diverse individuals in both urban and remote rural areas (Paterson, Osborne & Gregory 2004). Nursing education programs have sought to develop strategies that could provide students with cost-effective learning opportunities that would increase their cultural competency while increasing the number of nurses providing care in remote areas (Nairn et al 2004; Paterson, Osborne & Gregory 2004; Rutledge et al 2004). Strategies that have been instituted include computer-based programs, high performance simulators, standardised patients, and culturally oriented curricula (Nairn et al 2004; Paterson, Osborne & Gregory 2004; Rutledge et al 2004). Many schools provide some of these components; however, very few have linked them together.
BACKGROUND Due to globalisation, many countries have experienced a significant shift in the racial and ethnic composition of their populations. A prime example of this is in the United States where it is projected that by the year 2025 about 40 percent of adults and 48 percent of children in the United States will be from racial and ethnic minority groups (Department of Health and Human Services [DHHS] 1999). By the year 2050, people of color will represent one in three Americans (US Census Bureau 2000). Minority Americans are poorer (incomes below 200% of poverty) than white Americans (Kaiser Family Foundation 2007). Approximately 70 percent of elderly Hispanics and twothirds of elderly African Americans are poor or 120
CN
Volume 28, Issue 1–2, April 2008
KAY PALMER School of Nursing Old Dominion University Norfolk VA, USA
near poor (Kaiser Family Foundation 2007). In 2005, five million more Americans were uninsured than in 2001. People of color from lowincome families are at greater risk of being uninsured, and therefore more likely to experience disparities in access and quality of healthcare (Kaiser Family Foundation 2007). The National Healthcare Disparities Report [NHDR] (2005) stated that disparities in the American healthcare system still do exist in relationship to race, ethnicity, and socioeconomic status. According to the NHDR (2005), Hispanics and the poor are experiencing more disparities in quality of care than any other population. Minority populations rate their overall health worse than non-Hispanic whites and the poor of all races report worse health than higher income populations (Kaiser Family Foundation 2007). There is a definite relationship between life span and mortality in minority populations. African Americans have a higher death rate from breast, lung, and colorectal cancer than any of the other ethnic group (Kaiser Family Foundation 2007). Hispanics, African Americans and American Indians/Alaskan Natives are more likely to develop and die from diabetes than any other ethnic group (DHHS 2005). The rate of new AIDS cases among African Americans was over three times higher than the rate of among whites in 2003 (DHHS 2005). HIV is one of the five leading causes of death for African Americans and Hispanics between the ages of 25 and 44 years (Kaiser Family Foundation 2007). In order to achieve and maintain health, individuals need a source of health information, screening, and treatment that is accessible and culturally sensitive (Council on Collegiate Edu-
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 121
Integrative simulation: A novel approach to educating culturally competent nurses cation for Nursing [CCEN] 2003).The ability of individuals to obtain the most effective and appropriate care is affected by the ability of the patient to seek care and share concerns with the provider honestly and without fear. Healthcare providers should have an awareness and understanding of their patient’s culture in order to provide appropriate, quality healthcare (CCEN 2003). It is imperative that health professionals recognise their own biases and preconceived assumptions in order to overcome their impact on the provider–patient relationship (Nairn et al 2004; Rutledge et al 2004;Varcoe & McCromick 2006). A model that can assist the healthcare professional in becoming culturally competent is the Process of Cultural Competence in the Delivery of Healthcare Services model by CampinhaBacote (2003). According to this model, cultural competence is a process and not an event. The process of cultural competence consists of five inter-related constructs: cultural desire, cultural awareness, cultural knowledge, cultural skill, and cultural encounters.This model stresses that there is a direct relationship between the health care professional’s level of cultural competence and their ability to provide culturally responsive care. Utilisation of this model can enhance the cultural competence of the healthcare professional, and thus improve the access to healthcare and quality of care to all populations. The purpose of this paper is to present an integrative program that utilises simulation to provide baccalaureate nursing students with experiences needed to become culturally competent. This program was funded by a Health Resources and Services Administration (HRSA) grant from the United States Department of Health and Human Services. The Institutional Review Board at the University reviewed and approved the proposal for the protection of human subjects. All data was presented in aggregate form and no names or other identifiers were included with any of the data. The Campinha-Bacote Model of Cultural Compe-
CN
tency (2003) was used as the framework for the development of this program. Data indicates that the program has been well-received by the students, standardised patients, and faculty. Students are now able to address cultural issues through relatively safe and non-threatening encounters with cultures they may not otherwise be exposed.
OVERVIEW OF PROGRAM This nursing curriculum offers pre-licensure (university-based) and post-licensure (distance web-based) students a unique, pragmatic learning environment utilising a combination of a virtual web-based hospital, video-taped high performance simulator (HPS) experiences and the use of a personal response system (PRS) to enhance learning through meaningful preparation, simulated cases, feedback and debriefing. The cases presented through this virtual format have been enhanced to include cultural issues that may significantly impact the care of the patient presented. Faculty has been trained to provide the cultural content through three HRSA funded workshops with CampinhaBacote (2003), and two other in-house workshops. In addition, Campinha-Bacote serves as a consultant to the project. Cultural diversity is defined in a broad context based on ethnicity, age, gender, religion, sexual orientation, and/or special concerns such as disability. Simulation cases are developed from findings obtained during focus group meeting with various cultural groups. By using videotaped simulation encounters and the virtual web-based hospital, both university-based and distance learning students are able to participate in similar learning experiences.The program is outlined in Figure 1.
FOCUS GROUPS Focus groups are utilised to develop the virtual scenarios so that the students are provided with realistic virtual encounters that are based on the patient rather than educator perspectives. Focus groups, originally called focused interviews,
Volume 28, Issue 1–2, April 2008
CN
121
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 122
Carolyn M Rutledge et al Focus Group
Monarch General Hospital (Virtual Hospital)
High Performance Simulator (Simulated Mannequin)
Video Taping
Personal Response System (PRS) FIGURE 1: INTEGRATED
CULTURAL COMPETENCY SIMULATION PROGRAM
have been commonly used in social science research to collect information about the perceptions of individuals on a defined area of interest in a permissive, non-threatening environment (Morgan & Krueger 1998). Using a discussion format, focus group sessions are guided by a skilled facilitator who encourages participants to share their ideas and perceptions. They are seen as an ideal way to collect information about cultural diversity perspectives for this program. The information obtained through the focus groups is being used to develop the clinical scenarios and train the standardised patient for the virtual hospital encounters. Specific emphases of the focus group sessions are on culture-specific barriers to care and effective methods of overcoming the barriers. The focus group members are encouraged to share their experiences, desires, and recommendations regarding healthcare. A semi-struc122
CN
Volume 28, Issue 1–2, April 2008
tured discussion guide focusing on barriers and facilitators to access, quality of care, interaction with healthcare providers and other factors associated with inpatient and outpatient settings is used by the facilitator to direct the discussion. Topics included in the guide include: 1. What barriers have you encountered as a ( ) in seeking health care? 2. What positive encounters have you had with health care providers? 3. Where do you prefer to receive your healthcare and why? and 4. What could providers do to make your healthcare encounters more relevant or useful? Each focus group meets one time and consists of 5–10 (average of 8) volunteers from the cultures that are prevalent in our region or at the distance sites.The participants are recruited
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 123
Integrative simulation: A novel approach to educating culturally competent nurses from cultural groups, church programs, and community organizations through word of mouth or flyers. Each participant completes a consent form prior to participating in the group. Participants have consisted of African American women and then men, Filipino Americans, abused women, lesbians, gays, Native Americans, the military, and the elderly. A facilitator leads each group while a secretary takes notes as well as records the encounter on an audiotape. Once the encounter is over, the secretary reviews the audiotape and transcribes the notes for use in developing the virtual scenarios. No names or other identifiers are used in conjunction with the data. The focus group transcripts are systematically analyzed for themes and patterns using methods described by Miles and Huberman (1994).
Monarch General Hospital (virtual hospital) Monarch General Hospital (MGH), a full-service computer generated virtual learning platform developed by the undergraduate faculty in this program, is used to provide students with any-time/any-place practice options via the web. This interactive learning venue allows for repetitive practice opportunities and the integration of culturally focused cases. Development of patient ‘full-motion video clips’ that respond to typed questions allows students to query patients and receive a response including verbal and body language cues mimicking actual encounters. A culturally diverse virtual patient population is limited only by the imagination of the creator/writers of the program.The use of Monarch General Hospital peopled with a culturally diverse patient population provides students access and exposure to virtual patients developed to expand cultural horizons. Students are able to practice obtaining a health history or communicating professionally with virtual patients. The virtual patient format not only provides access to culturally diverse encounters that may not be available in the student’s com-
CN
munity, it allows for repetition of encounters enhancing both competency and confidence. Each virtual patient scenario is developed based on the information obtained during the focus groups, individual interviews, and a review of literature focusing on various cultures (Base-Smith & Campinha-Bacote 2003; Brooks 1992: Purnell & Paulanka 2008). The faculty is then able to tailor each scenario to meet the learning needs of the students in their particular classes.The faculty works closely with the standardised patient program at a local medical school in training standardised patients (live patient actors) to present the cases. The standardised patient provides both verbal and nonverbal responses to a set of questions while being videotaped. Written consent is obtained from all standardised patients prior to taping. The videotapes are edited and vignettes are created that are linked to a lexicon based on terms that should be used by students during an interview.The vignettes are then loaded onto a computer program for access as part of MGH. At the current time, only faculty and students in the program have access to MGH. Both pre-licensure university-based and postlicensure distance students access the virtual patients in the Ambulatory Clinic of MGH through an internet address, using their university student e-mail name. Once in the virtual hospital, students access a patient based on the course in which they are enrolled. A photograph of the patient along with the ‘chief complaint’ appears on the student’s computer screen.The student then types questions for the patient. The patient’s video-taped response is triggered by the key word/s in the question. Students collect health history data by successfully interviewing the patient. Repetition of interviewing patients throughout the semester allows students to become adept at history taking/data gathering and allows the faculty to determine student accuracy and competence while providing feedback and corrections. Both pre-licensure university-based and post-licen-
Volume 28, Issue 1–2, April 2008
CN
123
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 124
Carolyn M Rutledge et al
sure distance students use the data gathered during the web-based interview to develop a concise, yet thorough report of the patient’s information as they would in a patient’s chart. The university-based students prepare a care plan or concept map to plan appropriate nursing and intra-disciplinary actions. Using the nursing care plan/concept map, the students then provide hands on care to the High Performance Simulator (simulated mannequin) during their in-school lab experience.This enables the students to address the physical needs of the patient while considering the cultural impact. Meaningful preparation prior to the simulation experience is a key to success in the lab, just as it is a key to success in the hospital.
High performance simulator (simulation mannequin) In order to prepare students for diverse clinical patient situations, the students spend time in each course practicing their skills and demonstrating their competencies on high performance simulators (HPS). The clinical laboratory setting consists of two high performance simulators, three Vita-Sim Annies, one Sim kid, and a virtual intravenous (IV) trainer.This high fidelity equipment is housed in a newly remodeled skills laboratory that includes medical-surgical, critical care, pediatric, and women’s health/OB areas. When the students arrive in the HPS lab, they are ‘introduced’ to the patient for whom they should be prepared to provide care. Next, students are assigned a character for the simulation role play including but not limited to primary nurse, physician, health care team member, or family member. The scenario coordinator gives report to the students to set the stage and the simulation scenario begins. The scenario is based on the interview the student had with the patient during the MGH encounter. Students are expected to provide care to the patient, and respond to the patient and family’s physical, psychosocial, and cultural 124
CN
Volume 28, Issue 1–2, April 2008
needs. A patient chart including a patient history, physician orders, laboratory and diagnostic data is available to the student. Additionally, the supplies needed to care for the patient are in the simulation room or simulation lab store room. Students are expected to discern what equipment will be required as well as demonstrate psychomotor competence in completing procedures. A faculty member has the ability to monitor the simulation experience and alter the programmed response to the scenario based on the student’s response, or lack thereof, to cues. Ceiling mounted video cameras are strategically located to record the students as they interact as a team with the simulated patient. As the students get involved in the case, they have stated that they quickly forget the video is running. The interactions may be simultaneously broadcast to fellow students participating in the same class for real time peer review or viewed by faculty on the office computer. Upon completion of the scenario, the students may move to the classroom setting to review the video and debrief their performance. Students are provided a DVD copy of their own interaction and are able to reflect on their performance during debriefing with faculty or peers. Prior to using the scenarios outside of the actual classroom, all students involved provide written permission.
Personal response system (PRS) The Personal Response System (PRS) is used to enhance the students’ learning related to the HPS activities. Students gather in a room and watch the videotaped encounter with the patient simulator. These videotaped encounters can be used with the students that just participated in the experience or as a learning experience with other students in the class. Faculty members can interject written questions about the scenario or student response on the screen. Questions can be prepared ahead of time on PowerPoint© slides or added during the class. Students then use their PRS system to log in and answer the question.This system enhances instruction and
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 125
Integrative simulation: A novel approach to educating culturally competent nurses critical thinking by engaging the student in an active learning process and stimulating discussion when there are divergent responses. The Personal Response System (PRS) is a remote with buttons that are pressed by students in order to answer questions posed in class. This format encourages all students to actively participate in the classroom discussion as well as provides the faculty with an assessment of the students’ knowledge.The PRS uses infrared wireless transmitters to allow students to respond to multiple choice, true/false, or numerical questions using the click of a button. At the end of the faculty pre-set response time, the distribution of student responses is displayed in color on the screen.The distribution is visible to both the faculty and the participants; however individual scores are not displayed on the screen.This enables the faculty to determine whether key points are being grasped thus assisting to direct the flow of the session. Additionally, the item analysis provides students with immediate feedback about their response while maintaining student anonymity. Upon the completion of the assessment, student grades can be imported directly into a variety of course management systems such as Blackboard.
Example of virtual encounter One of the cases developed for the program focuses on an overweight, elderly, African American woman who works at a job that does not provide her with health insurance. She suffers from diabetes, hypertension and joint pain.This case was chosen because of its many cultural implications, its prevalence, and its management difficulties (Base-Smith & Campinha-Bacote 2003). In order to obtain patient oriented information for the development of the scenario, a focus group and individual interviews were conducted. During the focus group and interview, several themes emerged.These included feelings that their care might be negatively affected due to their ethnicity and lack of insurance; that providers often did not tailor their recommen-
CN
dations to meet their cultural needs; that many providers were not attentive; and that some providers did not treat them with the respect they felt they deserved. Specific concerns for the focus group members included the impact that financial constraints, dietary preferences, safety, their role in the family, and cultural views regarding weight could have on their health and ability to make needed behavioral changes. Positive factors were associated with providers that took the time to find out what lifestyle changes would work in their lives and providers who seemed truly interested in helping them. Participants in the focus group stated that they would seek providers who demonstrated competence and caring over the provider’s ethnicity. The information from the focus group was then utilised to develop the scenario for MGH. An African American woman was hired from the standardised patient program at the local medical school. The standardised patient (SP) was trained in the scenario came to the videotaping dressed in clean but plain attire. Her character represented an individual with diabetes, hypertension, and joint disease. A faculty member cued the SP by asking the questions that a student should ask during an interview. The SP responded using terms and expressions that would be culturally appropriate. For instance, the SP stated that she couldn’t pay for all her medications due to having no insurance.The foods that were recommended were not what her family tended to eat. She also brought up safety issues impacting walking. At the end of the scenario, the SP stepped out of her character role and presented information to the students regarding cultural issues they needed to consider when caring for a patient with the cultural background that was presented. The students then develop a concept map based on the information they obtained during the interview. The concept map includes the role of different disciplines as well as family members in the care of the patient once hospitalized. The students use this information as
Volume 28, Issue 1–2, April 2008
CN
125
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 126
Carolyn M Rutledge et al
they provide care to the high performance simulator (HPS). The HPS has been programmed with different responses prior to the student encounter. Physical conditions can be presented such as attaching a leg that has an abscess as a result of her diabetes or giving the patient Cheyne-Stokes breathing.The lab values that are presented can represent problems such as hyperglycemia, hyperlipidemia, or kidney failure. The students are expected to respond to the patient and family needs considering the information they obtained during the interview they had with the patient during the MGH encounter. The encounter with the HPS is videotaped. This videotape can be used with the Personal Response System (PRS) to debrief the students that participated in the case, to educate a group of students in the classroom, or to provide educational opportunities to distance learning students participating in the same class. During the debriefing and classroom encounters, the videotape is shown.The instructor can stop the videotape and asks questions that are typed onto the screen. The students can respond using the PRS. The instructor can then provide information and stimulate discussion based on the students’ responses. For instance, the instructor may ask the student if the nurses in the video addressed the diabetic patient’s need to lose weight in a culturally sensitive manner.The student can select a yes/no response using the PRS. Once those scores are tallied, the instructor can give the student a choice of four responses that might have been more culturally sensitive. Based on the tallies of the scores, the instructor can then stimulate discussion on which item would be most appropriate and why. In order to provide similar information to post-licensure distance students, the encounter can be video-streamed onto the web. The students can review the videotape and respond to questions regarding the encounter. The questions can either be responded to during a chat 126
CN
Volume 28, Issue 1–2, April 2008
room encounter, through the discussion board on Blackboard, or through written assignments
Evaluation Initial data suggests that the integrative simulation program has been well received.The individuals that participated in the focus groups expressed how much they appreciated having health care professionals interested in hearing their ‘story.’ They believed that the healthcare they received would be substantially better if their views were taken into consideration. The focus group leader felt that the participants were very open with their views on health care. They found that the information obtained was easily utilised for the development of the patient scenarios for Monarch General Hospital. The scenarios for Monarch General Hospital are in the pilot phase.The standardised patients used to depict each scenario have felt that the scenarios accurately depict their culture and issues they have encountered in healthcare. A review of the scenarios by experts in the field has supported the accuracy of the scenarios. Students are able to have encounters with patients representing cultures they may not readily see in the clinical setting.The encounters are standardised so that the faculty is able to assess performance through various classroom assignments. Many of the assignments now contain a cultural emphasis that was not present in the past. Faculty has found the development of the cases to be relatively easy. The cases have allowed them to explore the students’ awareness and knowledge related to the provision of healthcare to members of various cultural groups. Students have found that they need assistance in initially navigating through the Monarch General format. Plans are in place to simplify the use of MGH and provide the students with additional training. The high performance simulators (HPS) have been well received by the patients and faculty. The students have stated that they feel the HPS experience prepares them for clinical encoun-
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 127
Integrative simulation: A novel approach to educating culturally competent nurses ters. For instance, several students were involved in a code shortly after practicing a code on the simulator. They felt that the code went more smoothly than in the past as a result of the practice sessions with the HPS. They even requested to see their previous video and have future sessions with the HPS. Faculty have been pleased that the students have practiced various patient encounters prior to working with real patients. This has resulted in better prepared students in the clinical setting. In addition, faculty can request that students review procedures with the HPS when they demonstrate difficulty. Both faculty and students have given positive feedback about the personal response system (PRS). Faculty commented that the Interwrite PRS software is easy to learn and use, the program allows for a variety of question formats, and faculty can choose whether to display quiz questions all at once or interspersed throughout the content. Faculty are pleased that assignments are graded by the PRS program and faculty only need to generate a quiz report. The ability to receive immediate feedback about student knowledge was cited as a helpful teaching tool since it allows the faculty to decide the amount of time that needs to be dedicated to each aspect of the course content being evaluated. Qualitative student comments include positive feedback at being able to have immediate feedback about an assignment score. They also saw the PRS as a ‘safe’ way to participate in class by answering questions without ‘risking’ stating a wrong answer in front of their peers.The students commented that the use of PRS throughout the class session requires them to pay more attention in class since they never know when a quiz question will pop up which resulted in improved test scores. Students are currently involved in completing assessment tools to assess their level of cultural competency prior to participating in the programs, at set intervals during the program, and at the completion of the program. These
CN
include surveys on general cultural competency and focus areas such as disability, alternative lifestyles, obesity, and the elderly. The cultural competency of the students is also assessed through course assignments, clinical logs, and the Clinical Performance Appraisal (a final paper where students explore their strengths and weaknesses as a nurse).
CONCLUSION The simulated patient program provides an excellent format for overcoming many of the barriers encountered in nursing education. First, the simulated experience enables students to experience diverse situations in a controlled environment prior to working with actual patients. Students are able to make mistakes without compromising the safety of their patients. Through the debriefing, the students are able to learn from the encounters and develop strategies to overcome their weaknesses. Once weaknesses are identified, the students are able to practice their newly acquired skills using the MGH scenarios or the HPS. The students can also review their videos as often as they deem necessary. Through simulation, all students are able to participate with culturally-oriented patient situations that are deemed important for nursing students. It is not left up to chance in the reallife hospital environment where certain patient encounters may not be readily available to students. Furthermore, the students are able to focus on cultural issues and address the impact of their biases on patient care. The MGH encounters enable students to learn how culture impacts health and develop strategies to assist diverse patients in maximising their health. One of the difficulties often faced in providing web-based distance education is the ability to assess the clinical skills of students.Through on-line encounters with the patients in MGH hospital, the distance students can interview patients from diverse groups with various health concerns.This enables the faculty to assess their
Volume 28, Issue 1–2, April 2008
CN
127
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 128
Carolyn M Rutledge et al
interviewing skills and provide needed feedback.The video-streamed HPS encounters provide the distance students with the opportunity to address clinical care by discussing peer performance and responding to questions on the case that is presented. Finally, in an environment where clinical sites are at a premium and may be costly, the simulated environment can provide a cost-effective method for educating nursing students in clinical care. Furthermore, once developed, the clinical scenarios can be used year after year as well as with different educational programs.
References
Base-Smith V and Campinha-Bacote J (2003) The culture of obesity, Journal of National Black Nurses Association 14: 52–56. Brooks TR (1992) Pitfalls in communication with Hispanic and African American patients: Do translators help or harm? Journal of the National Medical Association 84: 941–947. Campinha-Bacote J (2003) The Process of Cultural Competence in the Delivery of Healthcare Services,Transcultural CARE Associates, Cincinnati OH. Council on Collegiate Education for Nursing, Southern Regional Board (2003) Preparing graduates to meet the needs of diverse populations, accessed at http://www. sreb.org on 19 January 2005. Department of Health and Human Services (1999) Mental Health:A report of the Surgeon General, US Public Health Service,Washington DC. Department of Health and Human Services (2005) National Healthcare Disparities Report, Agency for Healthcare Research and Quality, Rockville MD,
**
NOW
accessed at http://www.ahrq.gov/qual/nhdr05 /nhdr05.pdf on 8 June 2007. Kaiser Family Foundation (2007) Key facts: Race, ethnicity and medical care, accessed at http://www.census.gov /PressRelease/www/releases/archives/population/ 010048. html on 7 June 2007. Miles MB and Huberman AM (1994) Quantitative Data Analysis, 2nd edn, Sage,Thousand Oaks CA. Morgan DL and Krueger RA (1998) The Focus Group Kit, Sage,Thousand Oaks CA. Nairn S, Hardy C, Parumal L and Williams GA (2004) Multicultural or anti-racist teaching in nurse education: A critical appraisal, Nurse Education Today 24: 188–195. Paterson BL, Osborne M and Gregory D (2004) How different can you be and still survive? Homogeneity and difference in clinical nursing education, International Journal of Nursing Education Scholarship 1:Article 2. Purnell LD and Paulanka BJ (2008) Transcultural Health Care:A Culturally Competent Approach, 3rd edn, FA Davis, Philadelphia, PA. Rutledge CM, Garzon L, Scott M and Karlowicz K (2004) Using standardised patients to teach and evaluate nurse practitioner students on cultural competency, International Journal of Nursing Education Scholarship 1: Article 17. US Census Bureau (2007) Minority Population Tops 100 Million, accessed at http://www.census.gov/Press Release/www/releases/archives/population/01004 8.html on 8 June 2007. Varcoe C and McCormick J (2007) Racing around the classroom margins: Race, racism and teaching nursing, in Young L and Paterson B (Eds) Learning Nursing: Developing a Student-Centered Learning Environment, pp 439–468, Lippincott,Williams & Wilkins, Philadelphia PA.
AVAILABLE
C OMPUTER A SSISTED M ULTIPLE
AND
**
B LENDED R ESEARCH M ETHODS
A special issue of International Journal of Multiple Research Approaches, volume 2 issue 1 ISBN 978-1-921348-04-4; ii + 126 pages; s/c; June 2008 Edited by Eugenio De Gregorio (Sapienza University of Rome) and Francesco Arcidiacono (University of Neuchâtel) with an epilogue by Pat Bazeley (Research Support P/L and ACU) Information: http://mra.e-contentmanagement.com/archives/vol/2/issue/1 eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
128
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:37 PM
Page 129
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 129–140.
Cultural competence in action for CAMHS: Development of a cultural competence assessment tool and training programme ABSTRACT Key Words CAMHS; cultural competence; Delphi method; measuring tool; Papadopoulos, Tilki and Taylor cultural competence model; nursing
This article details the development of a tool to measure the cultural competence of individuals working within the Children and Adolescent Mental Health Services (CAMHS).The CAMHS Cultural Competence in Action Tool – known as the CAMHS ‘CCATool’ – was one of the components of a national project which aimed at promoting cultural competence within CAMHS.The other component was a two day training programme. Both components were based on the Papadopoulos, Tilki and Taylor model of cultural competence development.The article also outlines the educational principles and learning strategies used in the training. Received 26 July 2007
Accepted 13 May 2008
CN
IRENA PAPADOPOULOS
MARY TILKI
SAVITA AYLING
Professor Transcultural Health and Nursing Head, Research Centre for Transcultural Studies in Health Middlesex University London UK
Principal Lecturer Member Research Centre for Transcultural Studies in Health Middlesex University London UK
National Black and Minority Ethnic Lead National CAMHS Support Service Care Services Improvement Partnership Department of Health London UK
INTRODUCTION
T
his article describes a national project aimed at developing and delivering a teambased, practice-focused model of continuous professional development to promote cultural
competence for individuals working within child and adolescent mental health services (CAMHS) in England, UK. Participating regions included East Midlands,Yorkshire and Humber, West Midlands, Greater Manchester, South West,
Volume 28, Issue 1–2, April 2008
CN
129
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:37 PM
Page 130
Irena Papadopoulos, Mary Tilki and Savita Ayling
North East, North London, Middlesex, South London and Eastern. Whilst the project consisted of a cultural competence assessment tool and an educational intervention, this article will primarily focus on the former and will only briefly refer to the latter, which will be the focus of a subsequent article. For brevity the project will be referred to as the ‘CAMHS project’. In recent years a number of events have led to questions being asked about the ability of the UK medical, mental health and care services to meet the needs of service users from Black and minority Ethnic (BME) communities.The death, in 1998, in a medium secure psychiatric unit of a 38-year-old black patient, David ‘Rocky’ Bennett, and the publication by the National Institute for Mental Health in England, of the Inside Outside (Sashidharan 2003) report contributed to the development of Delivering Race Equality in Mental Health Care (DRE) (DH 2005). This is a five year action plan for ‘achieving equality and tackling discrimination in mental health services in England for all people of Black and minority ethnic (BME) status, including those of Irish or Mediterranean origin and east European migrants’ (DH 2005: 3). While DRE is an age-inclusive plan, and therefore covers the arena of Children and Adolescent Mental Health Services (CAMHS), there are other imperatives impacting onto CAMH services in England that have raised questions about how culturally competent the CAMH service is. These include the Public Service Agreement (PSA) (DH 2002) for a Comprehensive CAMHS by December 2006, and the five outcomes of Every Child Matters (ECM) (http:// tinyurl.com/2hd2qu) as follows, of which the most relevant is ‘be healthy’: • Be healthy; • Stay safe; • Enjoy and achieve; • Make a positive contribution; • Achieve economic well-being. 130
CN
Volume 28, Issue 1–2, April 2008
Standard 9 of the National Service Framework for Children,Young People and Maternity Services:The mental health and psychological well-being of children and young people (DH 2004: 41) defines Comprehensive CAMHS thus: ‘All children and young people, from birth to their eighteenth birthday, who have mental health problems and disorders have access to timely, integrated, high quality, multi-disciplinary mental health services to ensure effective assessment’. The underpinning principles to the definition go further by stating that, ‘Access to CAMHS should be available to all children and young people regardless of their age, gender, race, religion, ability, class, culture, ethnicity or sexuality’ (DH 2004: 48, Appendix II). As part of its work in supporting CAMH services in England towards achieving Comprehensive CAMHS in line with the PSA target, the National CAMHS Support Service (NCSS) undertook to review the levels of cultural competence within CAMHS nationally. The review evidenced much of what had been suspected anecdotally, that levels of cultural competence varied significantly throughout CAMHS. This was also borne out by the findings of the Self Assessment Matrix (DH 2003) undertaken on a voluntary basis by CAMHS services and in which all London CAMH services identified meeting the needs of BME service users as being their second most challenging problem. These reviews mirrored what was evident in the research literature.
NEED FOR CULTURAL
COMPETENCE IN CAMHS Despite a growing body of literature on the relationship between adult mental health and ethnic and cultural factors, CAMHS services in the UK have been slow to address the ethnocultural needs of children, adolescents and their families (Malek 2004; Timimi & Maitra 2005). The incidence of mental ill-health among young people is growing as are the numbers of chil-
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 131
Development of a cultural competence assessment tool and training programme dren and adolescents from minority ethnic and migrant communities. There is an extensive body of literature relating to cultural issues in adult mental health but research in the CAMHS area is sparse. However there is an expanding critique of mainstream practice and a call for wider debate and different ways of understanding the mental health of young people (Timimi & Maitra 2005). It is argued that cultural incompetence exists among health professionals (Maitra 2005) and that this leads to misdiagnosis and inappropriate treatment.There are particular concerns about increasing medication to children with behavioural problems many of whom are children from minority ethnic groups (Timimi 2005). There are concerns about the validity of diagnostic categories such as Attention Deficit and Hyperactivity Disorder (ADHD) and childhood depression generally but little attention is paid to differing cultural norms around childhood behaviour (Whitfield 2005; Maitra 2005;Timimi 2005). There are major concerns about acc ess, racism and cultural competence, yet despite policy initiatives over the last 20 years, little progress has been made in addressing race equality in CAMHS (Lowe 2006). Although the Race Relations Amendment Act (2000) requires public authorities to address racism, the Audit Commission (2004) highlights late, sporadic and superficial compliance with legislation by public service providers (Lowe 2006). The Audit Commission listed a number of barriers to progressing the equality agenda which include unexplored assumptions, institutional behaviours, resistance from staff and confusion about what should be achieved. Culley (2001) argues that legislation cannot tackle values and racist attitudes which persist in the hearts and minds of individuals. According to Husband (2000), inequality remains unchallenged because minority ethnic people are not seen by the majority community as truly equal or deserving, despite liberal notions of tolerance by the powerful.
CN
AIMS OF THE PROJECT In order to address the above challenges the NCSS commissioned the development of a set of learning tools that could be offered to CAMHS workers as a model to promote individual cultural competence. Having researched what was already being done in mental health services, the NCSS commissioned the Centre for Transcultural Studies in Health at Middlesex University, who had previously conducted a similar project with adult mental health services, to work with them in developing these tools and delivering a national programme addressing the cultural competence of CAMHS workers. In this paper cultural competence is defined as ‘the process one goes through in order to continuously develop and refine one’s capacity to provide effective health care, taking into consideration people’s cultural beliefs, behaviours and needs’ (Papadopoulos 2006: 11). This process involves the amalgamation of cultural awareness, cultural knowledge, and cultural sensitivity and their application to practice underpinned by an anti-discrimination and people empowerment ideology.
METHODOLOGY As stated above the CAMHS project builds on a similar one which two of the authors (IP and MT) had generated within the adult mental health services (Papadopoulos et al 2004).This involved the development and validation of a tool to measure the cultural competence of mental health workers using the Delphi method,1 and the development of a short training programme in consultation with key members of the commissioning organisation. Both the training programme and the assessment tool were designed using the structure and principles of the Papadopoulos, Tilki and Taylor (1998) model for developing cultural competence (Figure 1). The assessment tool contained culture-generic and culture-specific statements. The authors posit that the culture-
Volume 28, Issue 1–2, April 2008
CN
131
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 132
Irena Papadopoulos, Mary Tilki and Savita Ayling CULTURAL COMPETENCE
CULTURAL AWARENESS • • • •
• Assessment skills • Diagnostic skills • Clinical skills • Challenging and addressing prejudice, discrimination and inequalities
Self awareness Cultural identity Heritage adherence Ethnocentricity
CULTURAL KNOWLEDGE
CULTURAL SENSITIVITY
• Health beliefs and behaviours • Stereotyping • Ethnohistory/anthropological understanding • Sociological understanding • Psychological and biological understanding • Similarities and variations
FIGURE 1: PAPADOPOULOS, TILKI
AND
• Empathy • Interpersonal/communication skills • Trust • Acceptance • Appropriateness • Respect
TAYLOR MODEL
generic statements apply to all client groups and practitioners.When adjusting the original tool (known as the CCATool) to use with practitioners other than those of adult mental health, some of the wording of the culture-generic statements may be changed without affecting its validity. For example the word ‘client’ may be changed to ‘patient’. Only the culture-specific statements may need to be replaced when considered necessary.Therefore, a Delphi exercise to develop a new tool based on the original would only need to deal with any new culturespecific statements.The original tool contained 10 statements in each of the four domains being assessed (cultural awareness, cultural knowledge, cultural sensitivity and cultural practice). To maintain the integrity of the scoring formula, any new tool must retain the same number of statements per domain. However, during a Delphi exercise any number of new culturespecific statements can be processed in order to identify the actual number needed. 132
CN
Volume 28, Issue 1–2, April 2008
FOR
DEVELOPING CULTURAL COMPETENCE
DEVELOPMENT OF THE CAMHS ASSESSMENT TOOL FOR CULTURAL COMPETENCE Developing the CAMHS CCATool involved a number of steps. Step one of the process began with rewording some of the culture-generic statements in the original tool in order to reflect the specific context and client groups. For example the term ‘client’ was replaced by ‘children and young people’ or ‘service users’. As mentioned above, these changes do not affect the meaning of the statements which are therefore not considered to be new. Table 1 provides an example of these changes.The new statement is denoted with the word NEW in brackets. Step two entailed the identification of new culture-specific statements to replace those in the original CCATool which were not relevant. Initially this was done by the authors based on their expert knowledge and a thorough review of the literature.Table 2 provides an example of step one and two.
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 133
Development of a cultural competence assessment tool and training programme TABLE 1: REWORDING
1 2
3 4
5 6 7
8
9
10
OF
CN
CAMHS TOOL – ASSESSING CULTURAL AWARENESS
Original statements (mental health)
New statements (CAMHS)
Cultural upbringing impacts on the way in which individuals view other people People from different ethnic groups share many of the same values and beliefs as people from the host community There are many differences in values and beliefs within any single ethnic group Gender, age, class and generation are as important as ethnicity in forming a person’s identity Ethnic identity changes with time and the influence of wider social factors Some aspects of culture are more important to a person than others People select the most relevant aspects of their culture in different situations
Wording unchanged
People from different ethnic groups may have the same needs but they may be expressed in different ways To avoid imposing values on a client practitioners should be aware of their own value and belief systems Ethnic identity is influenced by personal, social and psychological factors
During step three the expert panel was identified following intense discussion. It was agreed that experts should meet one of the following criteria: • Be an experienced CAMHS practitioner/ service provider (statutory and/or voluntary sectors); • Be a CAMHS manager; • Be a CAMHS policy maker at national level; • Be an expert on culture and mental health (academic/researcher with relevant practice background). Eight experts were selected. There are no clear directions in the literature regarding the optimal panel size. McKenna (1994) reports that personal contact with experts seems to result in a high response rate; all our experts were spoken to either in person or on the telephone by one of the authors (SA). They were
Wording unchanged
Wording unchanged Gender, age, religion, ability and sexuality are as important as ethnicity in forming a young person’s identity (NEW) Wording unchanged Some aspects of culture are more important to a child and young person than others Children and young people choose the most relevant aspects of their culture in different situations Children and young people from different ethnic groups may have the same needs but they may be expressed in different ways To avoid imposing values on a service user practitioners should be aware of their own value and belief systems Wording unchanged
subsequently informed in writing of the aims and background of the project, that their participation would be voluntary and that their views would remain confidential.They were asked to indicate their consent to be involved. Four documents were sent to the panellists. The first provided the background of the exercise and instructions on what the experts had to do. The second was a brief outline of the Papadopoulos,Tilki and Taylor model (PTT) of Cultural Competence which underpinned the assessment tool. The third was the original (existing) tool (CCATool) with added new client group/s specific statements, and the fourth was the ‘questionnaire’ with the new culture-specific statements which they were asked to complete. They were encouraged to contact one of the authors (IP) if they had any queries or needed further information. One of the selected experts declined the invitation to take
Volume 28, Issue 1–2, April 2008
CN
133
CNJ 28_1_2_internal.qxd
CN
2
3 4 5
6
7 8
9
10
12:38 PM
Page 134
Irena Papadopoulos, Mary Tilki and Savita Ayling
TABLE 2: REPLACEMENT
1
14/07/2008
CULTURE - SPECIFIC STATEMENTS IN ORIGINAL
Original statements (mental health)
New statements (CAMHS)
Monitoring the ethnicity of all clients can help identify the effectiveness of service access and delivery Effective care requires an adequate knowledge of the client’s culture It is not possible to have full knowledge of all cultures There is much to be learned from the folk systems of the client People from minority ethnic groups have particular difficulty accessing day care services
Monitoring the ethnicity of all service users can help identify the effectiveness of service access and delivery Effective care requires an adequate knowledge of the service users’ culture Wording unchanged
Discrimination and harassment in everyday life leads people to engage in behaviours which may be damaging to their mental health Compulsory admission / detention rates are higher for black people Black people with mental health problems are more likely to have contact with the criminal justice system It is important to acknowledge particular cultural beliefs and practices in relation to mental health of minority ethnic groups Clients who perceive themselves to be possessed by spirits are invariably mentally disturbed
11
12
13
14
15
16
part as he was due to leave the country for an extensive lecture tour abroad. Another indicated, soon after agreeing to take part that an excessive workload was making it impossible to respond.This person was replaced. The questionnaire contained only the new 134
CCATOOL
CN
Volume 28, Issue 1–2, April 2008
There is much to be learned from the folk systems of the service user and of his/her family Children, young people and families from minority ethnic groups have particular difficulty accessing specialist CAMHS Discrimination and harassment in everyday life leads children and young people to engage in behaviours which may be damaging to their mental health Omitted Young black men with mental health problems are more likely to have contact with the criminal justice system It is not important to acknowledge particular cultural beliefs and practices in relation to mental health of minority ethnic children and young people Children and young people who are mentally disturbed are perceived by their families and communities to be possessed by spirits Adolescent African and Caribbean males are more likely to be inappropriately referred to adult mental health services (NEW) Practitioners never place too much emphasis on culture prior to exploring the complexity of the mental health problem (NEW) Practitioners who dismiss the cultural background of the child and young person ignore the complexity of the mental health problem (NEW) There is a need to achieve a balance between dismissing the culture and recognising how it contributes to complex mental health problems (NEW) There is a need to achieve a balance between attributing all mental health problems to culture, and recognising how culture contributes to complex mental health problems (NEW) Young African and Caribbean men are overrepresented in tier 3 & 4 CAMHS services (NEW)
CAMHS specific statements which panellists were asked to rate on a five point Likert scale ranging from ‘not at all important’ to ‘always important’. In addition, they were asked to comment on the wording of the statements they rated and to provide any statements which they
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 135
Development of a cultural competence assessment tool and training programme considered important for the CAMHS CCATool but had not been included in the questionnaire. They were asked to write their suggested statements as unambiguously as possible.This constituted step four of the process. Step five of the process involved the collation of the results from six of the seven experts who returned their questionnaires. Unfortunately two experts did not rate the statements as requested but provided suggestions on a small number of items they wanted to reword and comments on the areas they wished to have included on the tool, but they did not provide any specific statements. By only commenting on the changes they wished to see, it appeared that they were indicating an agreement with the statements they had not rated or commented on. All those who rated the new statements agreed that the new statement in the ‘cultural awareness’ domain was either ‘very important’ TABLE 3: NEW
1 2 3 4 5
6 7
8 9
10 11
ITEMS IN
CULTURAL SENSITIVITY
CN
or ‘always important’. One of the two who did not provide ratings suggested that statements on disability and domestic violence should be included in this domain. Five of the nine new statements in the ‘cultural knowledge’ domain were rated as ‘very important’ or ‘always important’. Three of the nine new statements in this domain were rated as ‘important’ or ‘very important’; however, one statement was rated by one expert as ‘not at all important’ whilst the other three experts rated it as ‘important’ or ‘always important’. Three experts offered other statements they wished to include whilst one compared the rated statements and suggested the deletion of two of them which were very similar to another two. This was very helpful because the intention of the authors was to retain only ten statements in each domain.The two new items in the ‘cultural sensitivity’ domain (Table 3) and the three new
DOMAIN
Original statements (mental health)
New statements (CAMHS)
It is almost impossible to communicate with a client whose first language is not English Greeting family members before the service user may be appropriate in some minority ethnic groups Clients who avoid eye contact are always suspicious or withdrawn Practitioners need to be trained in the use of interpreters Interpreters and advocates need to be trained in order to effectively represent the best interests of the child and young person Service users from some minority ethnic groups can be very demanding It is important to discuss the impact of ethnicity on the therapeutic relationship where the client and practitioner are from different cultures Religion can be a source of comfort and reassurance for some clients People from minority ethnic groups get little benefit from psychological therapies
It is almost impossible to communicate with a service user whose first language is not English Wording unchanged
The stigma of mental illness is greater in some minority ethnic groups than in the host community
Children and young people who avoid eye contact are always suspicious or withdrawn Practitioners need to be trained in the use of age appropriate interpreters and advocates (NEW) Interpreters and advocates need to be trained in order to effectively represent the best interests of the child and young person Service users from some minority ethnic groups can be very demanding It is important to discuss the impact of ethnicity on the therapeutic relationship where the service user and practitioner are from different cultures Religion can be a source of comfort and reassurance for some children, young people and their families Children and young people from minority ethnic groups get little benefit from psychological therapies Wording unchanged Practitioners never allow their own fears to get in the way of developing trusting relationships with service users (NEW)
Volume 28, Issue 1–2, April 2008
CN
135
CNJ 28_1_2_internal.qxd
CN
3
12:38 PM
Page 136
Irena Papadopoulos, Mary Tilki and Savita Ayling
TABLE 4: NEW
1 2
14/07/2008
ITEMS IN
CULTURAL PRACTICE
DOMAIN
Original statements (mental health)
New statements (CAMHS)
Subtle forms of racism are as damaging as overt forms Institutional racism is seen in unwitting prejudice, ignorance and thoughtlessness Recognising and challenging institutional racism is the responsibility of each individual health practitioner
Wording unchanged Wording unchanged
User participation is a critical component of good practice and should be encouraged at all levels of service provision Professionals and clients need training in user participation Best practice can be achieved by joint partnership between statutory and voluntary sectors The expertise of the minority ethnic voluntary sector should be used more effectively to obtain advice on good practice
4
5 6 7
8
Professionals and service users need training in user participation Wording unchanged
Stereotypes always have an impact on how clients are assessed 9 Stereotypes may account for the high level of compulsory detention and treatment of people from minority ethnic groups 10 The type and route of medication should be based on sound clinical judgement of client need and the degree of danger to self and others 11
12
13
items in the ‘cultural practice’ domain (Table 4) were rated by all as ‘very important’ to ‘always important’. Only one expert offered additional statements for the ‘cultural sensitivity’ and ‘cultural practice’ domains. The results of the ratings indicated a high level of agreement. This assured the content validity of the new tool.The authors’ challenge was how to deal with the comments and suggestions which were offered by the experts, and whether or not to have another round of Delphi. After a detailed discussion it was agreed that due to the high level of agreement and the 136
CN
Volume 28, Issue 1–2, April 2008
Recognising and challenging institutional racism is the responsibility of each individual CAMHS practitioner Wording unchanged
The expertise of the minority ethnic voluntary sector should be used more effectively to obtain advice on good practice in working with children and young people Stereotypes always have an impact on how service users are assessed Omitted
Omitted
Assumptions about culture never influence the diagnosis and treatment of children and young people (NEW) Attention Deficit and Hyperactivity Disorder (ADHD) is less likely to be diagnosed in BME children and young people (NEW) It is always easier to engage BME families in the treatment and support of children and young people with mental health problems (NEW)
lack of time, the project would move to the next stage that of piloting the new tool once the final statements had been agreed by the authors as people having expertise in culture, mental health and CAMHS. The following decisions were taken regarding the qualitative data from the Delphi exercise: • Cultural awareness domain: Not to take up the suggestion by one of the experts to include statements on disability and domestic violence.The rationale for this was that notwithstanding the importance of both these areas
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 137
Development of a cultural competence assessment tool and training programme the focus of the assessment of cultural awareness was the awareness of the impact of culture and ethnicity on the self. • Cultural knowledge domain: One of the experts suggested that a statement should be added in this domain which necessitated the practitioners to challenge, explore and negotiate beliefs if they posed danger to the child or conflict with treatment.This expert also suggested a statement should be included which acknowledged the nature of immigration in the UK. Another expert suggested that the culture and ethnicity of a child or young person interconnects with other aspects of social disadvantage contributing to complex mental health problems in children and families and that there is a need to have an in-depth knowledge of specific and relevant cultures to work effectively in CAMHS. The authors felt that the latter suggestion was covered by the already validated statements No 2 and No 3 (see Table 2) in this domain. It was felt that statements on immigration were more generic in nature whilst the suggestion about challenging beliefs was more suited to the ‘cultural practice’ domain; proposed statement No 11 in the ‘cultural practice’ (see Table 4) domain was considered a suitable response to this suggestion. Based on the feedback and ratings of the panel the following ten statements were selected to be included in the ‘cultural knowledge’ domain: 1, 2, 3, 5, 6, 8, 9, 10, 11 and 13 (Table 2).
CN
to the second suggestion we acknowledged that it would be difficult to assess as some people may agree with it and some may have reservations about it. For this reason the authors decided not to use it. • Cultural practice domain: One expert offered the following statements: ‘Every practitioner must take personal responsibility for training in culturally sensitive practice’; ‘It is essential for BME children, young people and families to have access to a range of therapies suitable to their particular culture/ethnicity’; ‘It is essential for the practitioner to understand the issues of professional and personal power to work in a culturally sensitive way’.Whilst the first and third suggestions were very noble, it was difficult to see which of the other four new statements in this domain, which had gained a high level of agreement regarding their importance, we should exclude in order to have them. After much consideration it was agreed not to include these statements. Regarding the second suggestion, we felt that the issue highlighted in the statement was addressed by a number of other statements in the tool all be it from a different angle. The authors acknowledge the difficulty in these decisions particularly when there is a limit to the length of the instrument being designed. It could be argued that a lengthy instrument is more likely to be comprehensive whilst others may argue that a well designed shorter one may still capture the essence of that which is being measured in less laborious ways. In any case the instrument or tool being discussed here was firmly based on a pre-existing tried and tested model.
• Cultural sensitivity domain: One expert offered the following two statements: ‘It is essential for practitioners to enable children and young people to define/describe their own ethnicity/culture’ and ‘It is important for users to have someone from their own culture to work with them’. It was felt that the PILOT first suggestion was adequately catered for in The new CCATool for CAMHS was piloted the ‘cultural awareness’ domain as well as by with 47 individuals working within the CAMH statement No 7 in this domain.With regards services.Table 5 provides a combination of their
Volume 28, Issue 1–2, April 2008
CN
137
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 138
Irena Papadopoulos, Mary Tilki and Savita Ayling
TABLE 5: PROFESSIONAL BACKGROUNDS/ROLES CAMHS PILOTS Professional background/roles
OF
Number
Social worker Community development worker Psychologist (in various clinical roles) CAMHS/Mental health nurse Manager (with backgrounds in social work, nursing and psychology) Administrator Occupational therapist Psychiatrists TOTAL
5 7 6 11 7 4 5 2 47
professional backgrounds or roles. To test how well the set of statements (or items) in the tool measured cultural competence, the Cronbach’s alpha test was employed. If the average interitem correlation is high the alpha will be high and vice versa.This means that if the inter-item correlations are high, then the items are measuring the same underlying construct, in our case, that of ‘cultural competence’. A ‘good’ reliability is achieved if an alpha of 0.70 or higher is reached. Our tests revealed that the Cronbach´s alpha for the CAHMS CCATool was 0.763. This was a good result particularly as those who took part in the pilot came from a variety of professional backgrounds and occupied a variety of roles. Therefore no further changes needed to be made to the statements before administering the tool during the national training programme.The only changes which were made to the new CAMHS CCATool were on the demographic variables. In particular the feedback indicated that the ‘work’ categories needed to be re-worded to reflect more accurately the roles of people working in CAMHS.
OUTLINE OF THE TRAINING PROGRAMME Based on the mental health project which two of the authors (IP and MT) had undertaken previously, a two day training programme was negotiated with the NCSS. The first day of the 138
CN
Volume 28, Issue 1–2, April 2008
programme focused on cultural awareness and cultural knowledge whilst the second day focused on cultural sensitivity and cultural competence. Prior to the beginning of each programme (see regional programme sites), the attendees were asked to complete the CAMHS CCATool. This was voluntary and individuals were told that their scores would remain confidential and would be fed back to them individually at the end of the project by the National Black and Minority Ethnic Lead (SA).With the exception of three individuals all others completed the assessment tool. The educational principles used to underpin the training programme aimed to: • Respect and use trainees’ knowledge and experience. • Encourage reflection on existing knowledge and experience. • Encourage peer exchange of knowledge and experiences. • Add to existing knowledge and cognitive skills. • Acknowledge that a two-day course in cultural competence does not necessarily and immediately transform trainees into culturally competent practitioners. It is an opportunity to consolidate the trainees’ levels of cultural competence and provide the platform for further development and lifelong learning in cultural competence. • Be realistic. It is impossible to deliver a twoday course which will meet everyone’s expectations and needs. Acknowledge that trainees may be at different levels of cultural competence but aim for the middle level. • Emphasise anti-discriminatory/antiracist approaches (dealing with difficult issues). During the two-day programme, techniques were applied that promoted peer learning communities, problem based learning, and reflective learning. All these techniques necessitate the use of active and interactive learning such as self reflective activities and group discussions. How-
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 139
Development of a cultural competence assessment tool and training programme ever, we also used a very small number of short lectures which provided cultural knowledge efficiently in the time constraints associated with such a short programme. One of the important messages of the programme was that we are all cultural beings and therefore cultural competence is relevant to all aspects of everyone’s professional work. In order to help develop and maintain the ‘cultural competence habit’ an electronic mailing list was established at the end of the project. This provides the vehicle through which members can exchange information, ask for or provide advice, thus continuing the process of reflection and personal development. An information pack containing all the materials used during the training was also distributed to each participating team.
CONCLUSION The CAMHS project took place in 2006. To date, it remains the most extensive and coherent programme of cultural competence training and assessment in the UK. Nearly 200 individuals were assessed and trained. The programme continues to be delivered by local trainers who were trained to cascade the work of the authors.The assessment tool has been converted into a user-friendly software by one of the authors (IP) and has been licensed to all CAMHS regions in England. The programme has been evaluated by the authors and it is currently the focus of an external evaluation. The authors hope to publish more details on the delivery and evaluation of the programme in the near future. This article forms one of the outputs aimed at disseminating the authors’ experiences and sharing their approaches.
Endnote 1 The Delphi method has been used since the 1950s in industry (Lindeman 1975) but in the last 20 years it has become popular among health researchers. It is a technique involving a panel of experts in order to obtain group consensus on a particular topic
CN
(Polit & Hungler 1999, McKenna, 1994, Keeney, Hasson, & McKenna, 2001). The procedure is characterised by a series of rounds (usually two to three) of questionnaires asking the panel of experts to rate or rank items on their importance or level of agreement with them. Each round provides feedback on the results from the previous round (Irvine, 2005) with the process continuing until consensus is reached. In each round, a summary of responses to the previous round is fed back to the panellists. Therefore the Delphi method when used in the development of an assessment tool helps to identify the items which will compose the tool and assures the content validity of these through its rigorous methodological process.
References Audit Commission (2004) The Journey to Race Equality: Delivering improved services to local communities. Holbook Printers, Portsmouth. Children’s Green Paper (2003) Every Child Matters, Cm 5860,The Stationery Office, London. Accessed at http://www.everychildmatters .gov.uk/_files/EBE7EEAC90382663E0D5BBF 24C99A7AC on 23 July 2007. Culley L (2001) A critique of multiculturalism in healthcare: the challenge for nurse education. Journal of Advanced Nursing 23: 564–570. Department of Health (DH) (2002) Technical Note for the Spending Review 2002. Public Service Agreement. Department of Health, London. Department of Health (DH) (2003) CAMHS Assessment Matrix. National CAMHS Support Service. Department of Health, London. Department of Health (DH) (2004) National Service Framework for Children,Young People and Maternity Services: The mental health and psychological well-being of children and young people. Department of Health, London. Accessed at http://tinyurl.com/32z8n4 on 23 July 2007. Department of Health (DH) (2005) Delivering Race Equality in Mental Health Care:An action plan for reform inside and outside services and the Government’s response to the Independent inquiry into the death of David Bennett. Department of
Volume 28, Issue 1–2, April 2008
CN
139
CNJ 28_1_2_internal.qxd
CN
30/07/2008
10:06 PM
Page 140
Irena Papadopoulos, Mary Tilki and Savita Ayling
Health, London. Accessed at http://tinyurl .com/32z8n4 on 23 July 2007. Husband C (2000) Recognising diversity and developing skills: the proper role of transcultural communication. European Journal of Social Work 3: 225–234. Irvine F (2005) Exploring district nursing competencies in health promotion: the use of the Delphi technique. Journal of Clinical Nursing 14: 965–975. Keeney S, Hasson F and McKenna HP (2001) A critical review of the Delphi technique as a research methodology for nursing. International Journal of Nursing Studies 38: 195–200. Lindeman CA (1975) Delphi survey prioritising in clinical nursing research. Nursing Research 24: 434–441. Lowe F (2006) Containing persecutory anxiety: child and adolescent mental health services and Black and minority ethnic communities. Journal of Social Work Practice 20: 5–25. Maitra B (2004) The cultural relevance of the mental health disciplines. In Malek M & Joughin C (Eds) Mental Health Services for Minority Ethnic Children and Adolescents. Jessica Kingsley, London. Maitra B (2005) Culture and the mental health of children:The cutting edge of expertise. In Timimi S & Maitra B (Eds) CriticalVoices in Child and Adolescent Mental Health. Free Association Books, London. Malek M (2004) Understanding ethnicity and children’s mental health. In Malek M & Joughin C (Eds) Mental Health Services for Minority Ethnic Children and Adolescents. Jessica Kingsley, London. McKenna HP (1994) The Delphi technique: A
N O W
worthwhile research approach for nursing? Journal of Advanced Nursing 19: 1221–1225. Papadopoulos I (2006) The Papadopoulos,Tilki and Taylor model of developing Cultural Competence. In Papadopoulos I (Ed) Transcultural Health and Social Care: Development of Culturally Competent Practitioners. Churchill Livingstone Elsevier, Edinburgh. Papadopoulos I,Tilki M and Taylor G (1998) Transcultural Care.A guide for health care professionals. Quay Publications, Dinton Wilts. Papadopoulos I,Tilki M and Lees S (2004) Promoting cultural competence in health care through a research based intervention. Journal of Diversity in Health and Social Care 1: 107–115. Polit D and Hungler B (1999) Nursing Research, Principles and Methods. Lippincott, Philadelphia PA. Race Relations Amendment Act (2000) The Stationery Office, London. Sashidharan S (2003) Inside Outside: Improving mental health services for black and minority ethnic communities in England. National Institute for Mental Health England.The Stationery Office, London. Timimi S (2005) The politics of attention deficit hyperactivity disorder (ADHD) In Timimi S & Maitra B (Eds) Critical Voices in Child and Adolescent Mental Health. Free Association Books, London. Timimi S and Maitra B (2005) (Eds) CriticalVoices in Child and Adolescent Mental Health. Free Association Books, London. Whitfield C (2005) Childhood trauma as a cause of ADHD, aggressions, violence and anti-social behaviour. In Timimi S & Maitra B (Eds) Critical Voices in Child and Adolescent Mental Health. Free Association Books, London.
A V A I L A B L E
M URA S OLWATA K OSKER : W E S ALTWATER W OMEN By Ellie Gaffney AM; ISBN 978-0-9775742-0-9; iv + 112 pages; s/c; Verdant House; 2006 Ellie Gaffney was a strong advocate both within Australia and internationally (including her address to the United Nations on Indigenous Rights) of the interests and welfare of Torres Strait Islanders. She has been particularly committed to advancing the rights of Indigenous women. As an administrator, Ellie Gaffney played a significant part in the development of hostel accommodation and primary health care for all Torres Strait Islanders. This memoir is a fitting reminder of the work and stature of a dedicated woman. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected]; www.e-contentmanagement.com
140
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 141
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 141–148.
Cultural desire: ‘Caught’ or ‘taught’? ABSTRACT
Key Words culture; nursing; healthcare; competence; transcultural; desire
There has been much discussion in the literature on what constitutes cultural competence training in nursing education and practice.The health profession literature supports a growing consensus that cultural competency curricular content should focus on attitudes, skills and knowledge. However, affective constructs, such as cultural desire, have received little attention in the transcultural health care literature. Some argue that affective constructs such as desire must be ‘caught’ rather than ‘taught,’ for how does one objectively measure or evaluate whether or not a student has obtained cultural desire? The purpose of this article is to explore more fully the construct of cultural desire in an attempt to identify meaningful ways that cultural desire can not only be ‘caught’ by faculty who model this construct, but also be ‘taught’ within nursing curricula as a foundational component of cultural competence. Received 24 May 2007
Accepted 20 March 2008
CN
in the transcultural health care literature. Some argue that affective constructs such as desire must be ‘caught’ rather than ‘taught,’ for how does one objectively measure or evaluate whether or not a student has obtained cultural JOSEPHA desire? The purpose of this article is to more CAMPINHA-BACOTE President fully explore the construct of cultural desire in Transcultural CARE an attempt to identify meaningful ways that culAssociates Cincinnati OH, USA tural desire can not only be ‘caught’ by faculty who model this construct, but also be ‘taught’ within nursing curricula as a foundational comINTRODUCTION here has been much discussion in the ponent of cultural competence. literature on what constitutes cultural competence in nursing education and practice (Lip- ‘Caught’ or ‘taught’? son & DeSantis 2007; Campinha-Bacote 2006a; It is without question that cultural desire repBetancourt 2007; Grant & Letzring 2003). Health resents an affective or attitudinal construct. profession literature supports a growing con- However, what is not clear is how it is to be sensus that cultural competency curricular con- incorporated into the cultural competence content should focus on attitudes, skills and tent of nursing curricula. Leng (2002) asserts knowledge. However, affective constructs, such that affective characteristics can be learned as cultural desire, have received little attention capabilities that affect human performances and
T
Volume 28, Issue 1–2, April 2008
CN
141
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 142
Josepha Campinha-Bacote
recommends a two-prong strategy of ‘taught and caught.’ He states that affective characteristics can be ‘caught’ from an informal environment like peer groups and field trips, while ‘more structured activities can include sharing of success stories, meeting with actual role models, role playing, simulations, using videos, games, the media, case studies, current affairs, personal encounters, autobiographies, biographies and testimonies from invited speakers to depict the desirable choices of affective characteristics’ (Leng 2002: 5). Using this approach, cultural desire can be ‘caught’ from other nursing students, faculty who model cultural desire, cultural encounters and/or invited speakers who are passionate about cultural competence in healthcare delivery. This approach can be evaluated through the use of such instruments as the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals–Revised (IAPCC-R) which measures the construct of cultural desire along with other constructs of cultural competence (CampinhaBacote 2007). The more difficult question is ‘How can cultural desire be taught?’ The Process of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote 2007) model of cultural competence can serve as a viable framework for teaching the construct of cultural desire.
Model of cultural competence The Process of Cultural Competence in the Delivery of Healthcare Services is a practice and educational model of cultural competence in healthcare delivery that defines cultural competence as the ongoing process in which the healthcare professional continuously strives to achieve the ability and availability to work effectively within the cultural context of the patient (individual, family, community) (CampinhaBacote 2007).This model requires nurses to see themselves as becoming culturally competent rather than being culturally competent and 142
CN
Volume 28, Issue 1–2, April 2008
involves the integration of cultural desire, cultural awareness, cultural knowledge, cultural skill and cultural encounters. Cultural competence is pictorially depicted as a volcano (see Figure 1) and symbolically, when cultural desire erupts, it gives forth the desire to ‘want to’ enter into the process of becoming culturally competent by genuinely seeking cultural encounters, obtaining cultural knowledge, possessing the skill to conduct culturally sensitive assessments and being humble to the process of cultural awareness. In this conceptualisation of cultural competence, it is clear that cultural desire is the foundational and pivotal construct of cultural competence.
FIGURE 1: PROCESS
OF CULTURAL COMPETENCE IN DELIVERY OF HEALTHCARE SERVICES
Source: © Campinha-Bacote 2002. Not to be reprinted without permission.
Cultural desire Cultural desire is defined as the motivation of the nurse to ‘want to’ engage in the process of becoming culturally competent; not the ‘have to’ (Campinha-Bacote 2003a). This motivation is genuine and authentic, with no hidden agendas. Rogers (1951) states that genuineness, or congruence, is the very basic ability of a person to read his own inner experience and allow the
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 143
Cultural desire:‘Caught’ or ‘taught’?
CN
suggests that the motivation of caring is importantly ‘other-directed’ as opposed to self. Individuals who are primarily committed to serving others above themselves can be characterised as having a ‘Servant’s Heart’ (Chapman 2005: 66). A Servant’s Heart symbolises love’s greatest expression, which assumes the full involvement of our best thought processes (Chapman 2005: 10). Chapman (2005: 12) adds, ‘Nurses don’t choose the nursing profession to become rich. The best nurses choose caregiving out of a passion to serve.’ Chapman (2005) supports a synergistic view of the concepts of love and caring, which he refers to as radical loving care. Radical loving care is not random thoughtful gestures. Radical loving care is defined as ‘creating a continuous Caring and love The concepts of caring and love are central to chain of caring light around each patient’ the construct of cultural desire. Cultural desire (Chapman 2005: 4) is based on the humanistic value of caring and the spiritual aspect of loving one another Sacrifice (Campinha-Bacote 2005). We are all unique Charles Dubois (nd) said: ‘The important thing individuals who belong to the same race – the is this: To be able at any moment to sacrifice human race, with similar basic human needs to what we are for what we could become.’ be cared for and loved. Our goal in providing Cultural desire encompasses the capacity to sacculturally competent nursing care is to seek this rifice. One must be willing to sacrifice one’s common ground. prejudice and biases towards culturally different Cultural desire mandates a genuine passion clients in order to develop cultural desire. and commitment to caring. May (1975) des- Howard (2003) adds that we must also sacrifice cribes care as ‘a state in which something does our ‘proprietary assumptions of our own rightmatter; it is the source of human tenderness.’ It ness and our unreflective grip on our own cerhas been said that people do not care how much tainty.’This type of sacrifice involves the moral you know, until they first know how much you commitment to care for all patients, regardless care.This type of caring comes from the heart; of their cultural values, beliefs or practices. not from the mouth (Campinha-Bacote 1998). The task of sacrifice may be difficult when The goal is not to offer comments that are pol- caring for challenging patients who engage in itically correct (words from the mouth), but behaviors that may be in direct moral conflict rather to offer comments to the patient that with the healthcare professional (eg abortion, reflect true caring (words from the heart). spousal abuse, sexual addictions). How does a Caring can be viewed as a virtue. When nurse care for a patient whose political and/or applied to the health professions, the virtue of religious beliefs are in direct contrast to their caring should be seen as a practical comport- beliefs? As healthcare professionals we do not ment towards others, which has the goal of have to accept the patient’s belief system, howenhancing the health-related existence of others ever, we must treat each person as a unique (van Hooft 1999: 193).Van Hoof (1999) further human being worthy and deserving of our quality of this inner experience to be apparent in the relationship. Cultural desire comes from one’s aspiration and not out of one’s desperation (CampinhaBacote 2005). It includes a genuine passion and commitment to be open and flexible with others; a respect and understanding of differences, yet a commitment to build upon similarities; a willingness to learn from patients and others as cultural informants; and a sense of humility (Campinha-Bacote 2003a).This article puts forward the assertion that the building blocks of cultural desire are caring and love, sacrifice, social justice, humility, compassion and sacred encounters.
Volume 28, Issue 1–2, April 2008
CN
143
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 144
Josepha Campinha-Bacote
love and care. In this sense, cultural desire is expressed in terms of human dignity, human rights, social justice and equity (CampinhaBacote 2006b).
Social justice Martin Luther King Jr once said, ‘Of all forms of inequality, injustice in health care is the most shocking and inhumane’ (King nd). Cultural competence must be based on a commitment to social justice. Culturally competent individuals have the skills necessary to break down systems of practice that perpetuate inequities (Ndura nd). Stacks, Salgado and Holmes (2004) calls for ‘socially just cultural competence’ and asserts that true cultural competence necessitates an understanding of social inequalities and how they affect individuals and communities. Hart, Hall and Henwood (2003) content that educators face a difficult task in preparing students to work with patients in ways that take account of differences in background and lifestyle and which respect human rights and dignity. These authors propose an ‘Inequalities Imagination’ model to enhance equality of care to all. This model makes explicit a process that assists nurses to move towards a greater understanding and awareness of the way they work with disadvantaged patients and offers strategies to bridge the gap between the challenges they face in day-to-day practice and what they need to achieve to aspire to provide equality care (Hart et al 2003). Research continues to demonstrate a direct correlation between inequality and negative health outcomes and it is because of this link that healthcare professionals must consciously connect cultural competence with social justice. Stacks et al (2004) contend that when cultural competence partners with social justice, we can finally achieve equality in health outcomes for all, regardless of race/ethnicity, language, gender, religion, or sexual orientation. Several nursing organisations have demon144
CN
Volume 28, Issue 1–2, April 2008
strated a commitment to social justice. The American Nurses Association’s Position Statement on Ethics and Human Rights (1991) supports this view, as evidenced in the following statements: • Human beings deserve respect as ends in themselves and therefore, deserve health care services that are equitable in terms of accessibility, availability, affordability and quality; • Justice requires that the differences among persons and groups are to be valued. When those differences contribute to the unequal distribution of the quality and quantity of health care, then remedial actions are obligated; • Because nursing care is an essential but sometimes limited commodity, allocation of care is a pressing issue that cannot be effectively addressed when specific individuals are excluded or when the burdens of limited access are borne by particular groups; • The principle of justice applies to nurses as providers as well as to nurses as recipients of care. ANA is committed to addressing the need for racial and ethnic diversity among nurses. Such diversity is a critical element in providing fair and equitable care. The Transcultural Nursing Society (TCNS) has made a recommitment ‘to safeguard human rights and quality health care through the discovery and implementation of culturally competent care’ by recently developing a Position Statement on Human Rights (Andrews et al 2007). This document serves as evidence that they are ‘committed to the rights of all peoples to enjoy their full human potential, including the highest attainable standard of health.’ The culturally competent nurse must become aware and sensitised to the overt and covert social inequities faced by others. This requires a community perception of the challenges of social justice for all. Therefore, a major step toward socially just cultural competence is to enter into community partnerships. ‘The process of becoming culturally competent
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 145
Cultural desire:‘Caught’ or ‘taught’?
CN
now moves outward from the individual, into humility.’ Cultural humility is defined as a lifelong commitment to self-evaluation and selfthe community’ (Stacks et al 2004: 5). critique, re-addressing the power imbalances in the patient-healthcare professional relationship Humility Humility is a quality of seeing the greatness in and developing mutually beneficial partnerships others and coming into the realisation of the with communities on behalf of individuals and dignity and worth of others. Nurses who are defined populations. humble have a genuine desire to discover how their patients think and feel differently from Compassion them. A humble person is generally thought to Compassion is an emotion of shared suffering be someone who does not think that he or she is and the desire to alleviate or reduce such sufferbetter or more important than others. Howev- ing as well as demonstrating kindness to those er, humility does not command us to consider who suffer. It is creating a space where patients ourselves lower in stature. Humility is not who suffer can tell their story to someone who thinking less of yourself; but thinking of your- can listen with real attention (Nouwen 1998). self, less. As quoted by Maya Angelou (nd), ‘There is no In integrating humility into the construct of greater agony than bearing an untold story cultural desire, it is helpful to view it as the inside you.’ Compassion is difficult because virtue of serving others. Matthew 20: 26–27 it necessitates that we enter into the pain of states, ‘but whoever wishes to become great another (Chapman 2005). among you shall be your servant and whoever Ironically, conflict can provide nurses with a wishes to be first among you shall be your slave’ unique opportunity for developing compassion – (New American Standard Bible 2002). The virtue the emotional task of sharing in one’s suffering. of humility, in this sense, is directed toward Mason Cooley (nd) reminds us that ‘compassion serving our fellow man. brings us to a stop and for a moment we rise However, there is said to be a paradox in pos- above ourselves.’ Culture is always a factor in sessing humility, for when we become aware of conflict, whether it plays a major role or influour humility and openly acknowledge it, we’ve ences it subtly (LeBaron 2003). LeBaron adds lost it. This begs the question: ‘Is it possible to ‘for any conflict that touches us where it matseek or learn humility?’ Drawing from the field ters, where we make meaning and hold our of theology, Ells (nd) argues that there are theo- identities, there is always a cultural component.’ logical ways to humble oneself that are found in When cross-cultural conflict arises, the goal is to the books of Proverbs, Philippians, Corinthians, respond with compassion. However, the obvious Matthew, Thessalonians, Ephesians and James question is, ‘How does one cultivate compassion (New American Standard Bible 2002). His exam- in the midst of cross-cultural conflict?’ ples include accepting a lowly place, receiving Arai (cited in Gallaher 2007) offers the correction and feedback from others graciously, following analogy regarding the relationship choosing to serve others, being quick to for- between conflict and compassion: ‘How are give, cultivating a grateful heart, purposely rocks polished? You put them in a tumbler, they speaking well of others and acknowledging your hit against each other, the sharp edges are wrongdoings to others. knocked off resulting in mutually polished stones. Tervalon and Murray-Garcia (1998) have The key term here is mutually.’ Cultivating comapplied the concept of humility to the process passion requires that we understand from the of becoming culturally competent healthcare other’s point of view and engage in self-reflecprofessionals and coined the term, ‘cultural tion of how our actions are affecting the other
Volume 28, Issue 1–2, April 2008
CN
145
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 146
Josepha Campinha-Bacote
person (Gallaher 2007). Gallaher adds that ‘understanding the point of view of the other means you are more likely to respond with compassion rather than judgment.’ During this reflection process one gradually comes into the awareness that we share more similarities than differences. Our sharp edges have been knocked off resulting in ‘polished hearts’ (Gallaher 2007).
‘Sacred encounters’ Compassion will lead nurses into a place of meeting in which there is ‘deep respect for differences and equally intentional openness to the possibility of connection’ (Howard 2003).This connection embodies an encounter, which Chapman (2005) calls ‘Sacred encounters’. Sacred encounters occur ‘whenever we meet another’s deep need with a loving response’ (Chapman 2005: 58). More simply put, it is the merging of love and need. Consider the following scenario: A patient is crying out with unimaginable pain. His cry seems to signal not only physical pain but fear, loneliness and sadness all in one. The nurses are barred from giving further relief medication because of the delicate nature of the patient’s condition. Instead, they simply stand by him and stroke his arm and hold his hand and struggle to soothe him with the soft instruments of their voices. They seem like two mothers trying to calm a crying baby – except that this is a full-grown man in exquisite pain. Still, one of them even refers to him as ‘baby,’ reinforcing how clearly she understands this patient’s deep need for the loving comfort of a mother. (Chapman 2005: 138) Chapman (2005) argues that loving care does not require twice the time, however it does require more than twice the presence. Every encounter is a cultural counter and our goal is to make each cultural encounter a Sacred encounter. 146
CN
Volume 28, Issue 1–2, April 2008
Summary Although there has been some consensus in the transcultural health care literature on what to teach in regard to the topic of cultural competence, there is no consensus on how to teach it – especially concerning affective or attitudinal constructs such as cultural desire. Before nurse educators can decide how to teach cultural desire, they must acquire an in-depth knowledge of this concept. Unfortunately the affective construct of cultural desire has been given little attention in the nursing literature. In order to more fully understand cultural desire and its components, this article has provided nurse educators and students with a closer examination of the construct. It is concluded that caring, love, sacrifice, social justice, humility, compassion and sacred encounters are salient components of cultural desire that must be addressed in the teaching of this construct. However, it is recommended that a formal concept analysis of cultural desire be conducted to further understand this construct. In addition, research is needed to propose the best ways to assess and measure this construct. As a certified transcultural nurse, I have recently developed a self-assessment instrument, Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Student Version (IAPCC-SV), to measure the construct of cultural desire of student nurses (Campinha-Bacote 2007). In measuring cultural desire, it is important to pursue both quantitative and qualitative measures.Therefore, mixed methods of evaluation are needed to assure that we have captured the breadth of cultural desire that may not be captured by quantitative tools alone. One recommendation is to use the quantitative measurement of the IAPCC-SV alongside of such qualitative measures as journaling, role playing, and field notes. Napoleon Hill (nd) remarks that, ‘The starting point of all achievement is desire. He adds that ‘weak desires bring weak results’ (Hill nd). It is desire that creates our future and if nursing
CNJ 28_1_2_internal.qxd
14/07/2008
12:38 PM
Page 147
Cultural desire:‘Caught’ or ‘taught’?
CN
cultural competence, Journal of Christian wants to create a future of rendering culturally Nursing 20: 20–22. competent care, it will have to be driven by desire. Cultural desire is the fuel necessary to Campinha-Bacote J (2003b) Cultural desire: draw us into a personal journey towards culThe key to unlocking cultural Competence, tural competence (Campinha-Bacote 2003a). Journal of Nursing Education 42: 239–240. Campinha-Bacote J (1998)The Process of Cultural References Competence in the Delivery of Healthcare Services: American Nurses Association (1991) Position A Culturally Competent Model of Care, 3rd edn, Statement on Ethics and Human Rights, accessed Transcultural C.A.R.E. Associates, Ohio. at http://nursingworld.org/ readroom/ Chapman E (2005) Radical Loving Care, Baptist position/ethics/etethr.htm on 19 March Healing Hospital,TN. 2007. Cooley M (nd) Mason Cooley Quotes, accessed Andrews M, Leininger M, Leuning C, Ludwigat http://www.brainyquote.com/quotes/ Beymer P, Miller J, Pacquiao D and Papadopauthors/m/mason_cooley.html on 21 May oulos R (2007) Transcultural Nursing Society 2007. Position Statement on Human Rights, accessed at Dubois C (nd) Wisdom Quotes, accessed at http://.www.tcns.org on 10 April 2007. http://www.wisdomquotes.com/cat_ Angelo M (n.d.) Maya Angelou Quotes, accessed sacrifice.html on 22 May 2007. at http://www.brainyquote.com/quotes/ Ells A (nd) What does the Bible say about ... authors/m/maya_angelou.html on 21 May Humility?, Bible.com, accessed at from 2007. http://www.bible.com/bibleanswers_ Betancourt J (2007) Commentary on ‘Current result.php?id=120 on 15 April 2007. approaches to integrating elements of Gallaher D (2007) Polishing the heart, Journal cultural competence in nursing education, of Scared Work, accessed at http://journalof Journal of Transcultural Nursing 18: 25S–27S. sacredwork.typepad.com/journal_of_sacred Campinha-Bacote J (2007) The Process of Cultural _work/ 2007/04/ polishing_the_h.htm on Competence in the Delivery of Healthcare Services: 13 April 2007. The Journey Continues, 5th edn,Transcultural Grant L and Letzring T (2003) Status of cultural C.A.R.E. Associates, Ohio. competence in nursing education: A literaCampinha-Bacote J (2006a) Cultural competure review, Journal of Multicultural Nursing & tence in nursing curricula: How are we doing Health 9: 6–13. 20 years later? Journal of Nursing Education 45: Hart A, Hal V and Henwood F (2003) Helping 243–244. health and social care professionals develop Campinha-Bacote J (2006b) Enhancing CARE an ‘inequalities imagination’: A model for use Through Transcultural Nursing:‘Can you in education and practice, Journal of Advanced paint with all the colors of the wind?’ Nursing 41: 480–489. Presentation at the 32nd Annual Conference Hill N (n.d.) Napoleon Hill quotes, Brainy of the Transcultural Nursing Society, Quotes, accessed at http://www.brainy Annapolis, MD. quote.com/quotes/authors/n/napoleon_ Campinha-Bacote J (2005) A Biblically Based hill.html on 22 May 2007. Model of Cultural Competence in the Delivery Howard G (2003) Speaking of difference: of Healthcare Services,Transcultural CARE Reflections on the possibility of culturally Associates, Ohio. competent conversation, New Horizons for Campinha-Bacote J (2003a) Cultural desire: Learning Online Journal 9(2), accessed at The development of a spiritual construct of
Volume 28, Issue 1–2, April 2008
CN
147
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:38 PM
Page 148
Josepha Campinha-Bacote
http://www.newhorizons.org/strategies/ multicultural/howard.htm on 15 April 2007. Jeffreys M (2006) Teaching Cultural Competence in Nursing and Health Care: Inquiry,Action and Innovation, Springer Publishing Company, NY. King M (nd) Cited in Molly Rush’s article, ‘Making universal healthcare a reality.’The Thomas Merton Center, accessed at http:// www.thomasmertoncenter.org/The_New_P eople/Nov2004/making_universal_healthca re_a_re.htm on 29 April 2007. LeBaron M (2003) Communication tools for understanding cultural differences:Beyond intractability, in Burgess G and Burgess H (Eds) Conflict Research Consortium, University of Colorado, Boulder, accessed at http://www .beyondintractability.org/essay/communicati on_tools/ on 10 April 2007. Leng Y (2002) Learner analysis in instructional design:The affective domain, CDTLink 6: 14–15, accessed at http://www.cdtl.nus.edu .sg/link/pdf/nov2002.pdf on 22 May 2007. Lipson J and DeSantis L (2007) Current approaches to integrating elements of cultural competence in nursing education, Journal of Transcultural Nursing 18: 10S–20S.
* * N O W
May R (1975) The Courage to Create, Bantam, NY. Ndura E (nd) The role of cultural competence in the creation of a culture of Nonviolence, Culture of Peace Online Journal 2: 39–48, accessed at http://www.copoj.ca/pdfs /Elavie.pdf on 15 April 2007. New American Standard Bible (2002) Zondervan, MI. Nouwen H (1998) Reaching Out, Zondervan, MI. Rogers C (1951) Client-Centered Therapy, Houghton Mifflin, MA. Stacks J, Salgado M and Holmes S (2004) Cultural competence and social justice: A partnership for change, Transitions 15: 4–5, accessed at http://www.advocatesfor youth.org/PUBLICATIONS/transitions /transitions1503.pdf on 10 April 2007. Tervalon M and Murray-Garcia J (1998) Cultural humility versus cultural competence: A critical distinction in defining physician-training outcomes in multicultural education, Journal of Health Care for the Poor and Underserved 9: 117–125. van Hooft S (1999) Acting from the virtue of caring in nursing, Nursing Ethics 6: 189–201.
A V A I L A B L E
* *
S O U L W O R K : F INDING THE W ORK Y OU L OVE , L OVING THE W ORK Y OU H AVE (Revised edition; January 2007; ISBN 978-0-9775742-3-0) Deborah P Bloch PhD, Professor, Department of Leadership Studies, University of San Francisco Lee J Richmond PhD, Professor, Loyola College in Maryland What programs address career development in an holistic way, including issues of meaning and purpose, spirituality, and ‘work within a life’? Written for career planners, executive coaches, life change counsellors, HR and human services managers and all those interested in employee development, workplace values, life-career assessment and personal transformation, this book helps to connect your career to the spiritual values that give your life meaning. SoulWork: Finding the Work you Love, Loving the Work You Have relates your career to spiritual themes, and aims to provide advice and support to people in working through their personal choices. Updated from 1998, the revised edition places career choices in the context of holistic, personal, spiritual development and internal change. A spiritual approach to integrating work/career with all life issues.
eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
148
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 149
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 149–161.
Perception of nursing care: Views of Saudi Arabian female nurses ABSTRACT
Key Words nursing; perception of care; values; Saudi Arabia; female Muslim nurses; Islam
‘Values are principles and standards that have meaning and worth to an individual, family, group, or community’ (Purnell & Paulanka 1998: 3).Values are central to the care provided by nurses.The provision of nursing care within the context of value clarification, has been explored from various perspectives, however, as values vary within cultures, there is a limited range of studies reflecting on Saudi Arabian nurses’ perspectives of nursing care. Through a Heideggerian phenomenological research design, six nurses were enrolled through purposive sampling. Semi-structured, in-depth interviews, which were audio tape-recorded, were chosen as the methods of data collection. A seven stage framework approach was applied to analyse and organise the research findings in three conceptual themes: values in context of Islam, the nurse-patient relationship, and identity’s influence on being in the world of nursing.The findings of the research indicate that values in nursing and the perception of care are closely linked to the Islamic values of the informants. However, one of the most challenging aspects emerging from this study is related to these nurses’ experiences related to the public’s negative perception of nursing as a profession for Saudi Arabian women. Received 6 July 2007
Accepted 26 April 2008
CN
INTRODUCTION Research setting/context JETTE MEBROUK Program Director Nursing Education and Research Nursing Affairs King Faisal Specialist Hospital & Research Center Jeddah, Saudi Arabia
T
he Kingdom of Saudi Arabia was founded in 1932 by King AbdulAziz Al Saud. The population of Saudi Arabia consists of approximately 17,000,000 of which Saudi nationals represent 72.7%, while expatriates of various origins comprise the rest (Ballal, Hafiz & Sebiany 2002). With the discovery of oil in the 1930s, a tremen-
Volume 28, Issue 1–2, April 2008
CN
149
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 150
Jette Mebrouk
dous development commenced. The development of industry, education and healthcare services quickly brought the country towards the standard of other industrialised countries (Ballal et al 2002).Today the Kingdom of Saudi Arabia has a population who has embraced the modern world while at the same time having held on to their cultural traditions and values.
Islamic worldview Islam, which connotes submission, surrender and obedience to Allah (Mawdudi 1985) is the fundamental religion of the society in Saudi Arabia, with the whole of the national population being Muslim. Qur’an is the holy script, and there are five pillars of Islam. Prophet Muhammad [PBUH1] said that Islam is based on five pillars: to testify that there is no god but Allah and that Muhammad is Allah’s apostle, to perform prayers, to pay obligatory charity, to perform pilgrimage, and to fast Ramadan (Alkhuli 2000: 46). While these aspects are mandatory in Islam, Sunnah, denoting the way Prophet Muhammad (PBUH) lived his life, is followed voluntarily by Muslims (Sunnah 2008). Muslims believe in the creation of man and woman, Adam and Eve, both coming from a single soul, whereby neither is better than the other, and every human being counts, as the life of each individual is sanctified (Elnaggar 2005). Muslims believe that humans have been given free will, but also that Allah knows their destiny (Hameed 2002). Actions that are permissible are termed Halal while prohibited actions are called Haram, and both these concepts are essential in practice of Islam. Rassool (2000) explains how the worldview of Muslim patients includes perception of illness, suffering and death as being part of life and a test from Allah, and that these aspects of life are to be addressed with patience, meditation and prayers. Women’s status within an Islamic oriented society has always been a controversial issue (Hassan 1999). Women have, based on Islamic values, essential roles as caregivers and home150
CN
Volume 28, Issue 1–2, April 2008
makers. It is difficult to separate Islamic and traditional values, but in general a woman is considered to possess qualities such as being gentle, caring and self-sacrificing. Men are complementarily considered to be protectors of women (Hassan 1999). Family is an essential factor in a Muslim’s life, and Islamic ethical values involve standards of behaviours that control relationship amongst family members, such as honesty, respect, obedience, decency, loyalty, mercy, sympathy, and truth-telling (Alkhuli 2000). Nursing in the Islamic context has roots back to the time of Prophet Muhammad (PBUH). Rufaidah bint Saad was known as the first Muslim nurse. She learned medical care by working together with her father who was a physician. In war times, Rufaidah cared with other volunteers for the wounded soldiers, and in times of peace she provided nursing care for sick patients in a tent outside the Prophet’s mosque in Madina (Kasule 2008).
Education in Saudi Arabia Formal education of females in Saudi Arabia developed radically in the beginning of the 1960s. At that time, women gained the opportunity to join formal education and universities, and become employed within a few sectors while being able to maintain the traditions and respect for the moral code of Islam (Megalli 2002; Doumato 1999). Nursing was one of the professions that opened to Saudi females. In collaboration with the World Health Organization (WHO), the Saudi Arabian Ministry of Health (MOH) opened the first nursing schools with a one-year program for men in the late 50s. A few years later similar programs for women were opened in Riyadh and Jeddah. In 1981 the admission criteria were raised from fifth and sixth grade to ninth grade entry level, and the curriculum was increased to a three-year program (Al-Osimy 1994).The Bachelor of Science in Nursing (BSN) was introduced in Saudi Arabia in 1976, followed by establishment of Masters Programs in 1987. A minimum of 12
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 151
Views of Saudi Arabian female nurses years of elementary and secondary education was required for entry to the BSN program (Tumulty 2001; Aldossary, White & Barriball 2008). Up until recently, all BSN programs have been exclusively for females. The first male BSN program was reported in 2006 to have 307 Saudi male students enrolled and distributed over the four years of academic program (MOH 1427H report). Although nursing education has undergone a tremendous development and the profession of nursing for females has Islamic roots, it is still a profession with societal stigma attached (Miller-Rosser, Chapman & Francis 2006).
Values and nursing care Leininger (1997) describes the premises of the Cultural Care Theory, where care is interlinked with cultural values, beliefs and practices that are influenced by and often embedded in the worldview, namely: language, philosophy, religion, kinship, social, political, legal, educational, economic, technological, ethno-historical, and environmental context of culture. ‘Values are principles and standards that have meaning and worth to an individual, family, group, or community’ (Purnell & Paulanka 1998: 3).Values are also a personal perception of what is ‘good and useful and contribute to self-evaluation and development of one’s identity.Within a specific culture, values refer to the persistent, powerful, and directive forces that give meaning and direction to the individual’s, group’s, family’s, or community’s actions, decisions and lifeways (Andrew & Boyle 1995). Culturally sensitive care based on patient and family’s values is fundamental to nursing. As values, culture and caring are core concepts within nursing, extensive literature and research have been published, with a focus on values and perspectives of the Muslim patient being care for by nurses of diverse cultural backgrounds (McKennis 1999; Lawrence & Rozmos 2001; Hammoud, White & Fetters 2005; Miklancie 2007). On the other hand, limited attention has
CN
been given to the caring relationship between the Muslim patient and Muslim nurse, particularly within the Saudi Arabian context.
Research questions The research focussed on exploration of Saudi female nurses’ experiences, seeking to answer the following questions: What are common aspects of their experiences in provision of care? Which values do Saudi Arabian female nurses perceive to be central to nursing care of Saudi Arabian patients? How does nursing influence everyday life of Saudi Arabian female nurses? And how does nursing give meaning to the Saudi Arabian female existence?
RESEARCH DESIGN Methodology Although philosophical understanding guides all research, and the choices of methodology depends on the project’s intent and the research problem (Wellard 1999), the great challenge to the researcher was to provide meaningfulness by applying the findings to nursing practice. Qualitative research methodology was selected, as it focuses on exploration of everyday lives of people and their experiences as seen from their perspective (Turner & Emden 2002).While various approaches exist within the qualitative research paradigm, the topic under investigation in this research was highly appropriate for a phenomenological research approach. Phenomenology is appealing to nursing research because it reflects upon values and beliefs. As phenomenology seeks to illuminate phenomena by uncovering unnoticed or overlooked aspects, it allows inquiry and discovery of unknown phenomena that are important to nursing, and it is through exploration of such questions that description of experiences further understanding of a phenomenon (O’Brian 2003). The process to discovery describes and analyses raw data in search of phenomena important to nursing care.
Volume 28, Issue 1–2, April 2008
CN
151
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 152
Jette Mebrouk
Selection of informants The researcher used purposive sampling, as this sampling method was thought to provide the richness of experience and perspectives on the concepts of caring, values, beliefs and how these are integrated in provision of nursing care. Inclusion criteria were set to ensure enrolment of appropriate informants. Saudi Arabian female nurses who graduated from a Saudi Arabian School of Nursing, with a minimum of one year of clinical nursing experience, the ability to speak English, and who were employed at the specific tertiary hospital in Saudi Arabia where the research took place, were selected. To prevent coercion, nurses in student roles undertaking one of the post-graduate nursing Diploma courses, and nurses working in the same department as the researcher were excluded from participation in the study. Adequate sample size in qualitative research is not dependent on the numbers of informants, but rather in the richness of data collected. In qualitative research the aim is to reach a stage of saturation of data, which refers to the stage where no new or controversial information is uncovered (Burns & Grove 2007). Initially six informants were included, but one withdrew from the study when she left the hospital, and no longer could take part in the research.The ages of the remaining five informants ranged from 23 to 26 years. All informants were born and raised in Saudi Arabia, were unmarried at the time of the study and had between one and three years of nursing experience after graduation. Data collection In Hermeneutic research, such as Heidegger phenomenology there is an interactive involvement of the researcher with the informants with the researcher becoming actively involved in the research, rather than a ‘passive onlooker’ (O’Brian 2003). This study used naturalistic interviewing as the data collection tool. The interviews were semi-structured, in-depth interviews, with open-ended questions. In the tra152
CN
Volume 28, Issue 1–2, April 2008
dition of phenomenology, the questions focussed on experiences of the informants with the intent of uncovering the informants’ perception of nursing care. Each informant met twice with the researcher for interviews, each averaging 45 minutes. Interviews were audio taped, and transcribed verbatim.
Data analysis Data analysis in qualitative research is distinctly different from data analysis in quantitative studies. One of the challenges faced by a researcher in a qualitative study with a large amount of narrative data, is how to apply a systematic approach when analysing the data (Taylor, Kermode & Roberts 2007). Data collected in phenomenological research will inevitably contain many words and phrases used by the informants to describe their experiences. Data analysis in this research was approached using Drauker’s (1999) seven stages of data analysis. The initial stage of the process was reading and re-reading interview transcripts while listening to the tapes to enhance comprehension of the written word and to gain recall of paralinguistic aspects of the conversation. Thereafter, an interpretive summary and manual colour coding of the text took place, which was the initial step in theme identification. In the next step, informants were involved if the researcher needed to seek clarification of ambiguous aspects. The researcher then reviewed the coding and initial themes, followed by comparing and contrasting of the data, whereby constitutive patterns that linked the themes were identified. The appropriateness of inter-rater reliability in qualitative research has been questioned, however where the investigator’s bias is especially likely to be perceived to be a problem, it may have a valid place (Pope, Ziebland & Mays 2000). Inter-rater reliability was used to address potential bias and ensure credibility of the research. A Masters prepared nurse performed an independent analysis based on the transcriptions, identifying main aspects. Dif-
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 153
Views of Saudi Arabian female nurses
CN
ferences between these and the researcher’s to build on a trust relationship with the inthemes were merely related to choice of words, formants. Data saturation, referring to the stage where which made no significant difference to the no new information is uncovered (Burns & meaning of the themes. Grove 2007) was achieved by undertaking two interviews with each of the five informants.The Ethical considerations Ethical approval for the research was obtained research methodology was not selected with a through the Institutional Review Board (IRB) of desire to provide a total representation of all the research setting and Deakin University Saudi Arabian female nurses. The informants Human Research Ethics Committee (DUHREC), were perceived by the researcher to represent Australia, where the researcher was enrolled in themselves, with the acknowledgment that each a Masters of Health Science (Nursing). Invita- individual person is unique. The study populations to participate in the research were sent to tion was, however, to some extent, considered potential informants in English and Arabic. Each to represent perception of care of Saudi Arabian informant provided informed consent before female nurses. enrolment in the research project, and was informed both verbally and in writing of their RESEARCH FINDINGS right to withdraw from the study at any time Lack of discussion or definition of the terms without any repercussion. Informants were theme and pattern seem to challenge readers of ensured confidentiality, which included secure qualitative research, when searching for the management and storage of the audio tapes and findings of the research (Sandelowski & Barroso the verbatim transcriptions of the interviews in 2002).The themes identified in this research are a lockable cabinet. Ethical considerations were defined as conceptual headlines within the Heialso addressed within the informant–researcher deggerian philosophy. The goal with this interrelationship. Although the research was not an- pretive study was to generate understanding, ticipated to be of potential risk for the inform- rather than to make generalisations, and the ants, Saudi Arabian female nurses are a minority value of each individual informant’s experience group, and the researcher did consider this in and perception were therefore of great imporplanning the interviews ensuring proper use of tance to the study. Data included under each the Islamic code of communication. theme may for this reason have originated from all of the informants or only from some of them.To give the reader insight into how comValidity of the research Validity in qualitative research should not be mon the aspect was, the researcher has included about strict adherence to a set of rules, but the number of informants who provided data rather about the faithfulness to the essence for each topic analysed.The data analysis generand notion of the research approach (Wellard ated could be group into three themes, namely: 1999). Lincoln and Cuba’s (1984) criteria of • Values in context of Islam; credibility, transferability, dependability and • The nurse–patient relationship; and conformability were sought as measures for • Identity’s influence on being in the world of nursing. validity in this study. Credibility can be addressed by field notes and research journal entries providing a research trail (Koch 1994). Theme 1: Values in context of Islam The researcher’s personal experience of work- Values in context of Islam emerged clearly with ing and living in Saudi Arabia also enabled contribution from all informants. The theme her with in-depth insight in the cultural context was constructed based on informants narratives
Volume 28, Issue 1–2, April 2008
CN
153
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 154
Jette Mebrouk
related to Qur’an,2 Sunnah,3 prayers, Zamzam, offer to pray with the patient, as prayers in the honey, end-of-life-care, and gender segregation. Islamic faith are known to improve well-being and the ability to deal with illness.
Holy Qur’an and Sunnah Three of the informants described how they used their Islamic belief consciously in their nursing care, by providing the patients with explanations for specific care interventions. Their explanations were based on two aspects; the Holy Qur’an and Sunnah that together form the base for the Saudi Arabian population’s way of existence (Daar & Al Khitamy 2001). One of these informants explained that she uses the tradition of Sunnah in her patient teaching. An example she used was regarding the importance of cleaning the skin before an injection, where she compared the Prophet’s (PBUH) emphasis on cleanliness to the reason for why it is necessary to clean skin before an injection. Another informant described how she consciously uses the Qur’an in combination with conventional interventions to help her patients:
Zamzam Zamzam, the holy water from the spring in Mecca, was mentioned by two of the informants as being important to Muslim patients and their treatment.The Zamzam was explained to have a curative role. At the same time, Zamzam was described as being used in addition to conventional treatment, such as using it instead of regular water when a patient takes his or her oral medication. One of the informants highlighted how she would ensure that the use of Zamzam would not compromise a patient’s health, by explaining that the Zamzam has to be boiled for patients with neutropoenia to reduce the intake of microorganisms. In this way she combined Islamic values and scientific reasoning to provide the best care for her patient.
Honey ... give him the antiemetic and I am here beside him, and I am reading the holy Qur’an for him, so it will make it much of a difference, because we all believe in the Qur’an and the role of it, the spiritual feeling. An informant also described how she continuously uses Islam to comfort palliative patients, by encouraging them to listen to recitations of the holy Qur’an or watch Islamic lessons on the television.
The use of honey was discussed by two informants, who mentioned that honey is considered, based on the holy Qur’an, to have a place in curative interventions.The two informants were giving patients advice on how to use honey appropriately. One of the informants advised her patients to avoid honey while being neutropoenic, and the other informant discussed the problem when diabetic patients want to eat honey. She explained how she would teach a diabetic patient that honey can be used in different ways, such as topically on wounds.
Prayers Using prayers as part of nursing care was described by two of the informants. Praying was connected to distorted psychological wellbeing, and was not replacing conventional treatment, but used complementarily. One of the informants explained how she respects the situation by avoiding interruption or walking in front of or in close proximity to the patient during prayer. She also explained how she would 154
CN
Volume 28, Issue 1–2, April 2008
End-of-life care It was highlighted by two of the informants that they incorporate religious considerations in the end-of-life care. While dying or soon after death, they would turn the patient to face Quibla, which is the direction of Mecca that all Muslims turn to for prayer. Specific ceremonial cleansing of the deceased was also mentioned by one of the informants.
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 155
Views of Saudi Arabian female nurses
Gender segregation All informants mentioned the importance of gender segregation, and described specific considerations to both male and female privacy.The informants would ensure that Saudi Arabian female patients remained appropriately covered at all times, even when unconscious. In spite of the societal value of gender segregation the three informants, who discussed the issue of taking care of male patients, did not report having major concerns if their patient assignment would involve care for a male patient. It was, however, mentioned that physical assessments that involved inspection of genital area were impossible, and that the nurse would be able to identify potential problems through conversation – an actual physical assessment would have to be performed by a male health care professional.
CN
munication. Descriptions of eye contact did however include concerns in relation to situations with male patients. Eye contact with male patients was not considered to be totally eliminated, and one of the informants referred to eye contact with a male relative as being inappropriate. She explained that she was cautious because men would not accept it and they would think she would be impolite if looking directly into their eyes. Touch was also considered an important aspect of communication when providing nursing care.This aspect was also incorporated with consideration to the gender of the patient. One of the informants described the touch of a male patient as:‘The professional touch.’ Smiling was mentioned as valuable in nursing care, and smiling did not appear to need special consideration for male patients. Smiling was even considered possible to use for nurses wearing face veil,4 as the eyes look different when smiling. One of the informants mentioned that patients can detect smiles in ways other than by seeing the actual smile, saying: ‘It will appear in my eyes and in my voice.’
Theme: Nurse–patient relationship Two subcategories, ‘communication’ and ‘qualities of the nurse’ were used to organise and present the findings for this theme.The topic of communication included verbal as well as nonverbal communication, while qualities of the nurse involved discussion on, helping and caring Qualities of the nurse about others. The informants used a variety of characteristics and values to describe a nurse and nursing care. These characteristics and values primarily adCommunication Verbal communication was first and foremost dressed the nurse–patient relationship. All indiscussed in relation to language. It was high- formants described, in various ways, their lighted that mastering of the Arabic language desire to help people. These were referring to would affect patients’ satisfaction and outcome. experiences of helping in restoration of health, One of the informants also described how she ensuring optimal treatment, patient’s acceptsaw value in both the patient and nurse speaking ance of the disease and situation, voicing queswith the same Arabic dialect. Language seemed tions and concerns, and achieve quality of life. for this informant to bond her and patient One specific way of helping was emphasised as: together while sharing common ground.Verbal ‘Trying to see things from patients’ perscommunication with medical focus was often pective’, which the nurse described as leading approached with a personal focused conversa- to personal and emotional involvement. To tion. Jokes and humour in the verbal communi- describe characteristics of a good nurse the cation were mentioned as being ways to relax informants included re-telling of experiences that described themselves or other nurses as patients by two of the informants. Eye contact was considered valuable for com- showing empathy, patience, and respect; being Volume 28, Issue 1–2, April 2008
CN
155
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 156
Jette Mebrouk
honest and trustworthy; and while being an active listener also being able to control emotions. Discussion about respect was approached from various angles.While the informants saw quality of a nurse to include respect, it was also stressed that they expected mutual respect from their patients and families.
Theme 3: Identity’s influence on being in the world of nursing Three categories, career choice, external factors, and internal factors, emerged during the data analysis and led to the theme identity’s influence of being in the world of nursing.
Career choice Medicine versus nursing as a profession was one of the topics that came up during the interviews. The informants unanimously expressed that their career choice had involved, at one time or another, a decision about whether to enrol in the medical school or the nursing school. There were different motivational factors involved in their choice to enrol and continue with their nursing studies.The informants were guided into the health care sector by their desire to help people. Two informants explained how they admired their mothers who were nurses, and how their choice of selecting nursing as career path was influenced by the way they saw their mothers caring for people. One of them explained: ‘In fact, inside me, I like to help people and that’s what I like my mother for, because she is caring about us and she is caring about people.’ Another informant described how she was motivated by the TV programs such as ER and 911.
factors were grouped under the category external factors.
Society’s view of nursing The society’s view of nursing directly influenced their identity.The informants described, in various terms, their experiences as challenging, in relation to the view of the society. One informant explained the comments that often were made by her patients: ‘The most common here in Saudi Arabia, if the patient really like you, and see that you are very good, they always ask: “Why are you in nursing?” “Why didn’t you study medicine?” ’ Another informant described how she thought the reason for the societal disapproval of women working as nurses is due to lack of gender segregation: They are looking at us like somebody strange … They are thinking that we are doing something wrong … They are rejecting us as nurses. They are refusing that we are working with males in the same area … they do not believe that this is the right job for a woman. While some TV programs had a positive effect on how society views nursing, other programs were seen as having a negative influence on the society’s perception. It was highlighted that it is not uncommon that nurses in Egyptian movies are portrayed as promiscuous or alcoholic, supporting the idea that female nurses engage in immoral behaviour.This view was also found to be promoted in a public debate within the newspapers, although the informants thought that recently this has changed and other perspectives are voiced.
External factors
Importance of the family’s Other factors that were found to influence the acceptance and support identity of the nurses were presented in discussions focused on experiences of the society’s view of nursing, the family’s acceptance and support, and teamwork in the workplace.These 156
CN
Volume 28, Issue 1–2, April 2008
The importance of the family’s acceptance and support was unanimously described.They generally expressed that their nursing career would not have been possible if they had not had the
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 157
Views of Saudi Arabian female nurses support of their families. Both parents’ opinions were found to be important to the informants; however, the fathers were often mentioned as playing a special role. One of the informants explained how she had modified her uniform in order to comply with the hospital’s policy of wearing pants, while meeting her father’s wish of having her wear a long dress. Another nurse explained how her father had supported her when she would come tired home from work. She reported that he would usually say to her: ‘It will be good for you and good for your patient, and as I know … that if you do anything good, God will reward you.’
Teamwork in the workplace Teamwork in nursing seemed to take an essential role in the development of identity. The informants saw themselves as part of a nursing team. One of the informants described how she saw it to be valuable that nurses would do a quick assessment and emergency intervention before calling the physician. Care was considered easily achievable through collaboration within the members of the team. One informant described the team’s work as placing pieces in a jigsaw puzzle, where everyone contributed and continued from where the previous nurse had let off.The desire for teamwork seemed to be strengthened during stressful situations.The importance of presence of team work and the informant’s ability to work within the team, helped creating a meaning of being in the world of nursing. At the same time teamwork created relationships between colleagues who collectively demonstrate concern for the patients and concern for each other.Teamwork is in this way closely linked to a caring relationship between colleagues.
CN
Self-realisation Discovering one’s self is essential to one’s identity, and self-discovery takes place throughout the lifespan. Lived experiences may make one come to self-realisation (Benner & Wruble 1989).The informants shared some of their selfdiscovery during the interviews. One of the informants explained how she had gone through a process: ‘I’m happy now in nursing. I know that life is not fair and it does not give me all that I want, but I am trying to find a way to adjust and be right with myself … I don’t want to live in conflict.’
Self-concept All of the informants explained their wish to continue their education with Masters degrees after they had gained more clinical experience. One of the informants explained that she would like to take a Masters degree and continue to work as a nurse, hoping to become a role model for other Saudi Arabian nurses. In this way, her self-concept became a link in an identity development, both for herself and potentially for the Saudi Arabian female nurses that she wanted to become a role model for.
Religious identity
Islam being fundamental to values in nursing care came so clearly through in the data analysis that a whole theme was dedicated to this aspect, at the same time Islam also came through as significant in exploration of identity. The informants unanimously reflected that they would not be nurses if it was not supported within Islam. Questions during the interview that from the researcher’s perspective had cultural focus were often answered with religious content. At times, the informants deliberately tried to separate the concept of culture and that of religion, but often Internal factors the informants answered as if culture and reliFactors such as self-realisation, self-concept and gion are synonymous. One of the informants religious identity were subcategories of the cat- expressed the essence of this inquiry as,‘our culture depends on our religion, which is Islam.’ egory internal factors.
Volume 28, Issue 1–2, April 2008
CN
157
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 158
Jette Mebrouk
DISCUSSION Religion is involved at various levels in different societies. In Western countries religion is often a private matter, where the individual might feel violated if they were addressed with religious expectation, particularly from persons that are stranger to them (Benn & Hyder 2002). Islam, for the Saudi Arabian population is, on the other hand, a public affair. Saudi Arabian nurses have a tacit understanding of the meaning of Islam. People in end-of-life situations frequently express belief that God has priority over life and can do more for patients than health care professionals can (Kagawa-Singer & Blackhall 2001). Similar perspectives were found incorporated in the experiences of the informants, who described how they respectfully would take care of the patient and the family by helping with the Islamic ritual during end-of-life. The informants’ familiarity with the culture, its population and the Islamic religion is merged in taken-for-granted practice, based on tacit understanding and actions. Gender segregation takes place in most societies. Public toilets are generally assigned by gender. Most hospitals, if not all, throughout the world, assign patients to shared rooms according to gender. However, gender segregation in Saudi Arabia is more strict, and is based on Islamic moral and ethical principles. It should not be underestimated that gender segregation is widely accepted in Saudi Arabia, and even though some of the informants in this study expressed that they do take care of male patients, many agreed that they would prefer gender segregation to greater extent. The informants in this research clearly perceived value in gender segregation, which reflects that stereotypical views of gender segregation being male dominance are misunderstandings or ethnocentric perspectives. The informants entered a relationship with their patients based on shared humanity. Experiences seemed to include combinations of universal human values and values based on the Islamic foundation. Values significant to the 158
CN
Volume 28, Issue 1–2, April 2008
Islamic society include principles of justice, brotherhood and a dynamic balance of right and obligations. The informants’ professional and personal identity appeared intertwined, and inseparable from Islamic values, and signifies how Islamic values penetrate the daily lives of all members of the society. Worldwide, communication is acknowledged to play a central role in the provision of nursing care, and while verbal and non-verbal communication in this research was identified to have similar importance for the Saudi Arabian female nurses, approach to such communication may be shaped differently. The issue of non-verbal communication for Saudi Arabian female nurses may be surrounded with some degree of preconceived ideas or bias due to the tradition of wearing face veil.The researcher had therefore prepared questions to explore the informants’ experiences in this regards. The informants reflected that non-verbal communication is not threatened due to application of a face veil, and it was found that there exists a taken-forgranted situation in this aspect as well. Verbal communication was often approached using icebreaking questions that were considered to create a bond between the patient and the nurse, and it was thought to be ideal to lead the conversation naturally over on the patient’s own concerns. Being and belonging in the world seemed to be extended through shared language. Communication is inherent in the nurse–patient relationship, although communication is approach differently depending on the gender of the patient and relative. The informants have discovered ways for them to practice nursing that incorporates the values of communication, while respecting fundamental principles and values of Islam. A large amount of the generated data seemed to be rooted in subjects related to the concept of identity. Nursing literature discusses two kinds of identity: personal identity and professional identity. Personal identity includes norms
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 159
Views of Saudi Arabian female nurses and values shaped by family, schooling, religion, and friends. Feelings, expectations, life experiences, body image, knowledge, and sense of self-worth are also aspects of personal identity. Professional identity encompasses characteristics in relation to the profession of nursing. These characteristics are common beliefs about nursing and are shared with other nurses (Bradley & Edinberg 1990). Professional identity, referred to as nursing identity, is a process that develops throughout professional nurses’ career (Cook, Glimer & Bess 2003). Career choices by Saudi Arabian women takes place within a complex interplay of family dynamics, Islamic values and the society’s influence (Lovering 1996). Complexity arises for Saudi Arabian women, as nursing is associated with the low status of nursing in Saudi Arabia (Littlewood & Yousuf 2000). Unlike teaching, nursing is not considered to be a traditional occupation for women (Marrone 1999). There was no description of an experience that led to exploration of professional autonomy except for one of the informants who described how she saw it to be valuable to do a quick assessment and emergency intervention before calling the physician. This may be linked to the Islamic values where honesty, respect, obedience, decency, loyalty, mercy, sympathy, and truth-telling are of central importance (Alkhuli 2000). It is though important to bear in mind that there were no questions that directly asked the informants to reflect upon autonomy. It may also be an effect of the fact that the Saudi Arabian society is of collectivist orientation, which may influence the individual to value autonomy differently than perhaps a nurse from an individualistic oriented society (Aboul-Enein 2002). Image of nursing is a challenge that faces the nursing profession throughout the world, but different factors may be at play in the context of the Islamic society of Saudi Arabia. It is a concern that was highlighted by the informants, and it is a topic that needs in-depth exploration in order to address it further.
CN
IMPLICATIONS FOR NURSING IN SAUDI ARABIA This phenomenological research project has taken interest in a minority group that has experienced limited attention in regards to perception of care. While exploring values, the problem of nursing for Saudi Arabian female was related to in terms of low image of nursing. Value of gender segregation of the population, including situations of health care is potentially going to be a much bigger problem that merely related to whether female nurses can provide care for male patients. While nursing still lack acknowledgement as a suitable profession for Saudi Arabian females, there is an increasing risk that Saudi Arabian females will become more reluctant to enter nursing schools, and this will become a conflicting situation that eventually will lead to significant problems in provision of care to the Saudi Arabian female population as the nursing shortage will increase.This research has demonstrated that Saudi Arabian female nurses are able to form caring relationships with their patients while maintaining their lifestyle based on Islamic values.
CONCLUSION This research has identified common aspects of nursing care experiences of Saudi Arabian female nurses, of which the significant importance of Islam was evident.Values were closely related to Islamic values, and signified the importance of Islam not only as an apparent religion in relation to faith, but a religion that saturate the entire lifestyle of the Saudi Arabian female nurses. The informants in this research have clarified how they practice nursing from such basis, while at the same time reflecting the predicament of the low image nursing in the Saudi Arabian society where nursing shortage is predicted to become worse as for the rest of the world. Recommendations of this research includes further investigation in the challenges Saudi Arabian nurses experience, and an exten-
Volume 28, Issue 1–2, April 2008
CN
159
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 160
Jette Mebrouk
sive exploration of the image of nursing in the Saudi Arabian cultural context.
Endnotes 1 PBUH stands for Peace Be Upon Him. It is said by Muslims after each time Prophet Muhammad (PBUH) is mentioned in writing as well as spoken communication. It is used in this article to signify the researcher’s respect of values of the informants and the Islamic society. 2 Qur’an meaning Koran is written in this way as the pronunciation of the word is best reflected as such, it also signifies the researcher’s sincere respect to the Saudi Arabian culture and the Islamic religion. 3 Sunnah is the term used for the traditional portion of Muslim law, based on the words and acts of Muhammad (PBUH). 4 Face veiling in Saudi Arabia is practised with several variations. While women who use face veil may choose in general to cover their eyes, this is not practised indoors in the health care setting. References Aboul-Enein FH (2002) Personal contemporary observations of nursing care in Saudi Arabia. International Journal of Nursing Practice 8: 228–230. Aldossary A,While A and Barriball L (2008) Health care and nursing in Saudi Arabia. International Nursing Review 55: 125–128. Alkhuli MA (2000) Morality in Islam, 1st edn, Dar Alfalah, Jordan. Al Osimy MH (1994) Nursing in Saudi Arabia. Saudi Arabia: King Fahad National Library Cataloging-in-Publication. Andrews MM and Boyle JS (1995) Transcultural Concepts In Nursing Care, 2nd edn, JB Lippincott: Philadelphia. Ballal SG, Hafiz AO and Sebiany AM (2002) Occupational health in Saudi Arabia. Occupational Medicine 17: 491–507. Benn C and Hyder AA (2002) Equity and 160
CN
Volume 28, Issue 1–2, April 2008
resource allocation in health care: Dialogue between Islam and Christianity. Medicine, Health Care and Philosophy 5: 181–189. Benner P and Wrubel J (1989) A phenomenological view of the person:The selfinterpreting being, in The Primacy of Caring: Stress and Coping in Health and Illness, pp 41–51, Addison-Wesley Publishing: Menlo Park, USA. Bradley JC and Edinberg MA (1990) Communication in the Nursing Context, 3rd edn, Northwalk: Connecticut, USA. Burns N and Grove SK (2007) Understanding Nursing Research. Building on Evidence-Based Practice, 4th edn, Elsevier: St Louis, Missouri. Cook TH, Gilmer MJ and Bess CJ (2003) Beginning students’ definitions of nursing: an inductive framework of professional identity. Journal of Nursing Education 42: 311–317. Daar SA and Al Khitamy AB (2001) Islamic bioethics. Canadian Medical Association Journal 164: 60–67. Doumato EA (1999) Women and work in Saudi Arabia: How flexible are Islamic margins? The Middle East Journal 53: 568–583. Draucker CB (1999).The critique of Heideggerian hermeneutical nursing research. Journal of Advanced Nursing 30: 360–373. Elnaggar M (2005) Islam and the Human Being, http://www.islamonline.net/english/introd ucingislam/Individual/article07.shtml retrieved on16/04/2008. Hameed S (2002) Fate and Free Will, http:// www.readingislam.com/servlet/Satellite?cid =1123996015716&pagename=IslamOnlineEnglish-AAbout_Islam/AskAboutIslamE /AskAboutIslamE last retrieved on 16/04/2008. Hammoud MM,White CB and Fetters MD (2005) Opening cultural doors: Providing culturally sensitive healthcare to Arab American and Arab Muslim patients. American Journal of Obstetrics & Gynecology 193: 1307–1311. Hassan AG (1999) The Rights and Duties ofWomen in Islam. Riyadh, Saudi Arabia: Darussalam.
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 161
Views of Saudi Arabian female nurses Kagawa-Singer M and Blackhall LJ (2001) Negotiating cross-cultural issues at the end of life ‘You got to go where he lives’. JAMA 286: 2993–3001. Kasule OH (2008) Rufaidah bint Saad, http:// www.crescentlife.com/thisthat/feminist%20 muslims/rufaida_bint_saad.htm last retrieved on 16/04/2008. Koch T (1994) Establishing rigour in qualitative research: the decision trail. Journal of Advanced Nursing 19: 976–986. Lawrence P and Rozmus C (2001) Culturally sensitive care of the Muslim patient. Journal of Transcultural Nursing 12: 228–233. Leininger M (1997) Overview of the theory of culture care with the ethnonursing research method. Journal of Trancultural Nursing 8: 32–52. Lincoln YS and Guba EG (1985) Naturalistic Inquiry. Sage,Thousand Oaks CA. Littlewood J and Yousuf S (2000) Primary health care in Saudi Arabia: Applying global aspects of health for all locally. Journal of Advanced Nursing 32: 675–681. Lovering S (1996) Saudi Nurse Leaders: Career Choices and Experiences. Unpublished Masters thesis, Massey University, New Zealand. Marrone SR (1999) Nursing in Saudi Arabia leadership development of a multicultural staff. JONA 29: 9–11. Mawdudi A (1985) Towards Understanding Islam, 2nd edn, Gassim: Saudi Arabia McKennis AT (1999) Caring for the Islamic patient. Association of Operating Room Nurses Journal 69: 1185–1202. Megalli M (2002) Saudi women face complex choices. Arab News. Retrieved through on-line service of Arab News, October 2003. Miklancie MA (2007) Caring for patients of diverse religious traditions: Islam a way of life for Muslims. Home Healthcare Nurse 25: 413–417. Miller-Rosser K, Chapman Y and Francis K (2006) Historical, cultural, and contem-
CN
porary influences on the status of women in nursing in Saudi Arabia. Online Journal of Issues in Nursing 11: 3. Ministry of Health (2006) Annual Report. www. moh.gov.sa/en. Retrieved 12 April 2008. O’Brian L (2003) Phenomenology. In Schneider Z, Elliott D, Beanland C, LoBiondo-Wood G and Haber J (Eds) Nursing Research Methods, Critical Appraisal and Utilization, 2nd edn, pp 193–204. Mosby, St Louis MO. Pope C, Ziebland S and Mays N (2000) Qualitative research in health care: Analysing qualitative data. British Medical Journal 320: 114–116. Purnell LD and Paulanka BJ (1998). Transcultural Health Care A Culturally Competent Approach. FA Davis Company: Philadelphia PA. Rassool GH (2000) The crescent and Islam: Healing, nursing and the spiritual dimension. Some considerations towards an understanding of the Islamic perspectives on caring. Journal of Advanced Nursing 32: 1476–1484. Sandelowski M and Barroso J (2002) Finding the finding in quantitative studies. Journal of Nursing Scholarship 34: 213–222. Sunnah (2008) Sunnah and Adherence, http:// www.unbsj.ca/clubs/msa/sunnah.html last retrieved on 16 April 2008. Taylor B, Kermode S and Roberts K (2007) Research in Nursing and Health Care: Evidence for Practice, 3rd edn, Melbourne, Australia. Tumulty G (2001) Professional development of nursing in Saudi Arabia. Journal of Nursing Scholarship 33: 285–292. Turner DS and Emden C (Eds) (2002) Interpretive Research Practices and Challenges. Monograph for module HNN722, Research Methodologies in Nursing. Deakin University, School of Nursing: Geelong, Australia. Wellard S (1999) ‘Research:Ventures in Knowing’, and ‘Issues of Validity in Research’. Research Methodologies in Nursing Study Guide for Module HNN 728. Geelong, Australia: Deakin University.
Volume 28, Issue 1–2, April 2008
CN
161
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 162
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 162–164.
CN
EDITORIAL Transcultural nursing: The global agenda
MARILYN (MARTY) DOUGLAS Associate Clinical Professor School of Nursing University of California San Francisco CA, USA
T
ranscultural nursing must be more than caring for the patients or clients who come through our doors. It is not and cannot be solely about those we serve in our small corner of the world. Just as the fluttering of butterfly wings on one side of the world can contribute to the formation of hurricanes half way around the globe, social, political and economic events in one hemisphere affect the lives of people in the other half. This reality is becoming more evident with each passing day as globalisation becomes more firmly rooted and the internet reaches the farthest corners of our planet. We are becoming global citizens, tied inextricably to each other.What affects one group of citizens has an impact on the lives of every other group. This interdependence, along with a sense of obligation and our common humanity, underlies the imperative for social justice when addressing the health care needs of our fellow world citizens. In the paper by Pacquiao (2008) that follows in this section, the author outlines the skills needed for world citizenship and describes how these skills form the basis for providing culturally competent care for vulnerable populations,
162
CN
Volume 28, Issue 1–2, April 2008
JULIENE G LIPSON Professor Emerita School of Nursing University of California San Francisco CA, USA
particularly those who have migrated because of political, economic or environmental dangers. Within this framework, she explains the concepts of social justice, human rights and compassion in relation to cultural competence. She offers a number of strategies for teaching these abstract concepts and skills to health care students and practitioners. Perhaps the timing of a new millennium has made the desire for change almost palpable in the air we breathe. Old political administrations are being defeated by electorates or parties who want to overturn that which has been, even if the new younger voices have not yet been tested.The mood is one of wanting something different from the old way of doing things, whether it is in Australia or the United States, Kenya, Russia, or the Middle East. But change can also cause chaos if it is not accomplished with care, especially when this change occurs within an unstable social or political context. In the world today there are many examples of change, chaos, unrest and increasing social inequality, which have resulted in many people on the move. Motion and chaos seem to define this current historical period. Whether from
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 163
Editorial: Transcultural nursing:The global agenda war that shifts populations to refugee camps, or the hopelessness of poverty that drives the able-bodied to seek work in more promising economies, many become refugees, pawns in human trade, asylum seekers, or voluntary migrants. Large numbers of nurses are among these resettled migrants, many recruited from the developing countries by the western industrialised countries whose aging populations need increased nursing care. These nurses face tremendous challenges, potential exploitation, and numerous barriers to the optimal use of their professional skills. Transcultural nursing mandates that the principles of social justice, human rights and cultural competence extend as much to our professional colleagues as they do to our patients and clients. In the paper by Mireille Kingma (2008) the author summarizes the scope and magnitude of the international nurse recruitment efforts and identifies the types of abuse, discrimination and exploitation reported by migrant nurses. The position of the International Council of Nurses (ICN) is presented along with its key principles for ethical recruitment and employment practices. In addition, ICN’s educational standards for assisting internationally-recruited nurses to adapt to their new environment are cited, as well as strategies for integrating these nurses into the host country’s organisational structure. Culturally competent nurses can help make the transition easier for their international colleagues by encouraging their education and professional growth through mentorship, compassion, patience and support. Ultimately, the learning becomes bidirectional; the mentor gains new insights about health care beliefs and practices from the mentee and vice versa. Vulnerable populations, whether on another side of the globe or indigenous to our own country, are a particular focus in transcultural nursing.The health care values, beliefs and practices of these populations may be as different from our own as those from another continent. Yet we may be blind to our own biases and prej-
CN
udices because of the prolonged exposure of living within a dominant society that has isolated and stigmatised these populations. One of the first steps in the process of gaining cultural competence entails self-reflection. One aspect is examining our own practice for evidence of racial discrimination that can lead to disparities in health outcomes due to the inherent biases of health care professionals. In Section 4 of this issue, the authors of two papers address culturally competent care of indigenous populations. McMurray and Param (2008) describe how structural, historical and political factors have contributed to the negative health status and health outcomes of Australia’s Aboriginal and Torres Strait Islander peoples. Included in these structural factors are barriers to health care access as well as biases of health care professionals themselves, especially when assessing and analysing health problems. Strategies for overcoming these barriers and biases are recommended by indigenous health professionals and organisations of professional health care providers in Australia. In the second paper, Wilson (2008) describes her research that explores the health perceptions of Ma-ori women and their interaction with ‘mainstream’ health care services. Results of her study provide guidance for her recommendations for culturally competent practice for these Ma-ori women. Finally, these two papers also illustrate the need for using culturally-appropriate research methods when investigating health problems of vulnerable populations. Sensitivity to the cultural norms of the group is necessary throughout the research process. To give an example from the US, permission of the tribal chief of an Indian population is required by institutional research review boards before initiation of any research with a tribe. However, obtaining this permission may be accompanied by difficulties in conducting the research. In some tribes, but not others, health care practices are considered the secret purview of the tribal healer and can-
Volume 28, Issue 1–2, April 2008
CN
163
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 164
Marilyn (Marty) Douglas and Juliene G Lipson
not be shared outside the tribe (Struthers et al 2005).Therefore the research may be limited by the questions that can be asked and the findings that may be published. Sensitivity to these issues can prevent a violation of trust, which could interfere with cross cultural communication and lead to misleading findings and irrelevant recommendations for practice. The papers in this section illustrate the nature and scope of transcultural nursing as a global endeavor. By incorporating the principles of social justice, human rights, compassion, and human dignity, transcultural nurses aim to provide culturally competent care to fellow world citizens, irrespective of their cultural origins, human condition or social situation. By integrating our clients’ cultural practices into their health care plan, we improve the probability of achieving positive health outcomes and meeting the primary objective of the World Health Organization (WHO), that of ‘attainment by all peoples of the highest possible level of health’.
References Kingma M (2008) Nurses on the move: Diversity and the work environment, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 198–206.
N E W
T I T L E
McMurray A and Param R (2008) Culturespecific care for Indigenous people: A primary health care perspective, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 165–172.
Pacquiao DF (2008) Nursing care of vulnerable populations using a framework of cultural competence, social justice and human rights, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 189–197.
Struthers R, Lauderdale J, Nichols LE,TomOrme L and Strickland CJ (2005) Respecting tribal traditions in research and publications, Journal of Transcultural Nursing 16: 193–201. Wilson D (2008) The significance of a culturally appropriate health service for Indigenous Maori women, Advances in Contemporary Transcultural Nursing, 2nd edn, Contemporary Nurse special issue 28(1–2): 173–188.
World Health Organization WHO (2006) Constitution of the World Health Organization. Basic Documents, 44th edn,WHO: Geneva, accessed at http://www.who.int/governance /eb/who_constitution_en.pdf on 29 February 2008.
A V A I L A B I L I T Y
P LEASE K NOCK B EFORE Y OU E NTER : A BORIGINAL REGULATION OF O UTSIDERS AND THE IMPLICATIONS FOR RESEARCHERS By Karen L Martin; ISBN 978-1-921214-37-0; 170 pp; Post Pressed; 2008 Karen Martin’s thesis was highly praised by two internationally renowned scholars. Professor Norman Denzin, (University of Illinois) remarked, ‘this is a brilliant and stunning dissertation, original in conception and bold in execution ... Relatedness theory is a major contribution to this literature.’ Professor Manulani Meyer, (University of Hawaii) celebrated this work for its cultural truth and integrity and wrote, ‘Her research showed flair, originality, depth and significant independent scholarship within an Aboriginal community. It has brought us new insights into a people and Nation that will help our own knowledge systems evolve ... Her work is timely.’ eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected]; www.e-contentmanagement.com
164
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 165
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 165–172.
Culture-specific care for Indigenous people: A primary health care perspective ABSTRACT
Key Words Indigenous culture; culture care; social inequality; Aboriginal health; primary health care
This article argues that a primary health care approach is an appropriate conceptual framework for addressing the health needs of Indigenous people. Primary health care is strategic, focusing on equity, access, empowerment and intersectoral partnerships as essential elements for maintaining health. Stereotypical notions of Indigenous ill health as being embedded in a general view of ‘culture’ can mitigate against achieving equity, access to health care and ultimately self-determinism. Because health is embedded in the social conditions of people’s lives, the emphasis in Indigenous health care should first address Indigenous social disadvantage and ways of working in partnership with various groups of Indigenous people to achieve their health goals. A critical multicultural approach situates cultural differences within the wider nexus of power relations, and helps overcome the negative stereotyping that often prevents inclusive, self-determined care. Recommendations are suggested for change at the societal, professional and individual level. Received 25 June 2007
Accepted 18 March 2008
CN
RANI PARAM ANNE MCMURRAY Chair in Nursing Peel Health Campus Murdoch University Perth WA, Australia
INTRODUCTION
P
rimary health care provides an ideal framework for conceptualising the issues and influences related to culturally appropriate care for Indigenous people. A primary health care approach is strategic, focusing on equity, access,
Lecturer Centre for Aboriginal Medical and Dental Health (CAMDH) The University of Western Australia Perth WA, Australia
empowerment and intersectoral partnerships as essential elements for maintaining health. Contemporary thinking in health and health care underlines the convergence of these central tenets of primary health care around inequalities embedded in the social conditions of peo-
Volume 28, Issue 1–2, April 2008
CN
165
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 166
Anne McMurray and Rani Param
ple’s lives. These social conditions determine where and how people live, and what opportunities exist for their education, employment and their capacity as parents and citizens (Whitehead 2007;World Health Organization [WHO] 2005).This is not to imply that a person’s social environment at one point in time predetermines health status and health outcomes across the life course. Circumstances can change, and inequities can be countered in numerous ways at different stages. However, a position of relative disadvantage from birth combined with exposure to adverse circumstances can create a systematic life exposure trajectory that plays out in both overt and subtle ways to constrain the capacity for a healthy and satisfying life (Hertzman & Power 2006). Unfortunately, this is the inequitable life situation for many Indigenous people. For nurses and other health professionals it poses a critical question as to whether and to what extent culture-specific care can redress health at birth and throughout the life course.
INDIGENOUS DISADVANTAGE Reports of disadvantage among the world’s 350 million Indigenous people are indisputable (Smith 2003). In Australia alone, a proliferation of data illustrates the extent to which our half a million Aboriginal and Torres Strait Islander people live in disadvantaged social conditions relative to other Australians (Australian Institute of Health and Welfare [AIHW] 2004; Australian Medical Association [AMA] 2007; Trewin & Madden 2005). The level of disadvantage has left Indigenous Australians with a 17 year disparity in life expectancy, and a mortality rate 4.6 times higher than the overall population (Trewin & Madden 2005). A comprehensive analysis of the plight of Aboriginal people, who represent 90% of Australian Indigenous people, show that they are at least twice as likely to have a profound or severe activity limitation, often from an earlier age (Trewin & Madden 2005). 166
CN
Volume 28, Issue 1–2, April 2008
Aboriginal Australians experience earlier onset of most chronic diseases, are three times more likely to have a major coronary event than nonAboriginal Australians (AMA 2007) and experience a disease prevalence of diabetes mellitus four times greater than non-Aboriginal people, resulting in five times the hospitalisation rate for this disease (Trewin & Madden 2005). Hospitalisation rates for respiratory diseases and injury among Aboriginal people is twice that of non-Aboriginal people and Aboriginal people have 12 times the rate of dialysis treatment for kidney disease (Trewin & Madden 2005). In terms of a healthy start to life, the infant mortality rate, prevalence of low birth weight, hospitalisation, malnutrition, and infection rates are substantially higher than among the general Australian community (AIHW 2004; Trewin & Madden 2005). In subsequent years, especially in remote areas, issues of transport, economic community and management issues related to food, education and other resources contribute to disadvantage by denying Aboriginal communities access to the fundamental elements of good health, education and social support. Social problems in some Aboriginal families can also compromise the health of children, including hazardous consumption of alcohol, family violence and poor parental mental health (Trewin & Madden 2005; Zubrick et al 2005). Poor family functioning is also rooted in socioeconomic disadvantage. The AMA (2007) describes the health disparities between Indigenous and non-Indigenous people as a national tragedy that shows our failings as a community. Despite recognition that Indigenous people have numerous financial, geographic, and personal barriers to accessing care, health professionals and social commentators alike are often inclined to attribute the poor health of Aboriginal people to culture, rather than structural, historical or political factors.The efficacy and feasibility of this assumption can only be logically challenged once we dispel the notion that Indigenous people repre-
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 167
Culture-specific care for Indigenous people: A primary health care perspective sent a monolithic society (Toussaint 2003). If this were the case, knowledge of Indigenous culture would afford health planners a set of culturally appropriate guidelines from which to develop culture-specific care. Since there is considerable diversity among Indigenous Australians a more realistic view can be illustrated through a critical multicultural approach, wherein health professionals develop alternative ways of thinking about Indigenous values and worldviews which don’t entail the reification of Indigenous culture as a set of fixed cultural properties (Culley 2006). Critical multiculturalism is reflexive, situating cultural differences within the wider nexus of power relations (Culley 2006). It is antiessentialist in that culture is not used to denote difference or to engender negative stereotyping. Instead, it should be seen as a movable social process, which does not limit professional practice to a deficit model, but rather, celebrates diversity and adopts inclusive strategies in all care planning (Culley 2006).The role of health professionals in this type of approach is based on close engagement with the group and an understanding that initiatives to improve health outcomes must emanate from within the group. Health professionals act as resource persons in genuine, authentic partnerships to seek political and structural solutions to health problems.This approach is congruent with primary health care, which also mandates that the health of the group is embedded in a broad, intersectoral approach that unravels the various interactions between culture, societal structures and social inequalities that create disadvantage for the particular Indigenous group.These interactions can reveal where barriers exist to accessing health care, or where they impede members of the group from becoming sufficiently health literate to make empowered decisions for better health. Before this level of empowerment is achieved, strategies to overcome historical disempowerment must be implemented.These focus on the conditions that promote awareness of vulner-
CN
ability, and that include representation members of the group at the tables where decisions are made, in equal standing with all parties. This is the key to achieving substantive freedom, what Nobel Prize winner Amartya Sen describes as having the capabilities to choose a life that a person has reason to value (Sen 1999). According to Pearson (2005) the end point of developing these capabilities is the development of a civil society; networks of families, communities and businesses that do not emerge from bureaucratic power, but from public order and safety and the motivation to develop skill, self-confidence and personal responsibility.
AUSTRALIAN INDIGENOUS SOCIETIES: COMMONALITIES AND DIFFERENCES Despite the commonalities that bind members of a cultural group, some behaviours, cultural traits and predispositions are often tacit aspects of behaviour; unconscious, shared predispositions that are not always expressed in the same way by all who claim membership in the group. Individual expressions of attitudes, beliefs and behaviours vary according to age, gender, personal histories, and situational factors, and these are, in turn, influenced by family, group and community influences. However, irrespective of the heterogeneity of Aboriginality (Toussaint 2003), as health professionals it is crucial to have some understanding of cultural norms and traditions. This knowledge helps health care providers understand different ways of thinking about health, life, and different perspectives of well-being. For example, cultural knowledge often prescribes diet and eating habits, childrearing practices, reactions to pain, stress and death, a sense of past, present and future, community and economic structures, responses to health care services and practitioners, and which behaviours are considered a violation of social norms (McMurray 2007). The most recognisable feature shared by many Volume 28, Issue 1–2, April 2008
CN
167
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 168
Anne McMurray and Rani Param
Indigenous cultures is a holistic, ecological, spiritual view of health and well-being.This encompasses physical, mental, cultural, and spiritual dimensions of health, and the harmonised interrelationships between these and environmental, ideological, political, social and economic conditions (Eckermann et al 2006; Mignone & O’Neil 2005; Swan & Raphael cited in Zubrick et al 2005;Toussaint 2003). At the centre of Aboriginal people’s relationship with each dimension of health is a fundamental spiritual connection with land, symbolising the ecological connection between health and place.This is a metaphysical connection, wherein the spiritual element governs all other inter-relationships. Historical factors are also significant in these relationships. Colonisation by non-Indigenous people and the political decisions that have ensued from colonisation have disrupted Indigenous people’s connection between health and place, leaving generations of Indigenous Australians feeling dispossessed of their place, both symbolically and geographically (Adelson 2005; Eckermann et al 2006; Pomaika’i Cook,Tarallo-Jensen,Withy & Berry 2005; Shore & Spicer 2004). Dispossession, as a marker of inequity and disadvantage, is therefore one of the most important issues that must be dealt with meaningfully if Indigenous people are to develop and enhance their capacity for health. Recognising and articulating the influence and impact of dispossession should therefore be the central organising principle in planning culturally sensitive care for any specific Indigenous group.This also lies at the forefront of the Australian Council for Aboriginal Reconciliation Commission’s (ACAR) goals, to try to bring to voice Indigenous history, the misunderstandings between Indigenous and non-Indigenous people, and the need to address disadvantage and disempowerment so that Indigenous Australians can achieve genuine selfdetermination (ACAR 1994). Achieving this begins by peeling back the layers of social inequality perpetrated by both historical factors and contemporary Australian social life. 168
CN
Volume 28, Issue 1–2, April 2008
SOCIAL INEQUALITIES Unravelling the various dimensions of inequality must begin with the recognition that a problem exists between Indigenous and non-Indigenous social life (Whitehead 2007). Failing to understand the persistence and multidimensional nature of health inequalities can lead to premature closure in defining the problem(s), and a tendency to dismiss health outcomes as being attributed to ‘culture’ when they need to be framed within structural features of political and social life, especially socioeconomic status (Whitehead 2007). For example, Indigenous women rarely have health problems examined in relation to gender issues.Yet gender relations are a significant part of the life of many Indigenous women, whose health problems may also vary considerably between geographic, socioeconomic and family situations.Timidity in grappling with issues of family violence, preventative care or the need for women’s education and empowerment can occur because of a lack of understanding or the inclination to assume that it is unwise to challenge the group’s gender relations and norms of behaviour. This line of logic is paradoxical in light of national television campaigns to illustrate appropriate norms of gendered behaviour in relation to violence against women, and by the legal system’s intolerance of minority groups using so-called cultural defence to justify sexual assault, as evidenced by the judicial conclusion of the notorious 2002 gang-rape of adolescent girls by four Pakistani-Muslim brothers (Adelman, Erez & Shalhoub-Kevorkian 2003). Among Aboriginal communities, increasing social inequality and the continuing effects of colonisation have destabilised traditional systems governing conflict resolution and gendered behaviours, leading to risky patterns of substance use, intergenerational stress and trauma, and physical and psychological abuse (Astbury et al 2000). Attributing high rates of family violence to ‘cultural factors’ or to how Indigenous Australians lived traditionally not only is blatantly
CNJ 28_1_2_internal.qxd
14/07/2008
12:41 PM
Page 169
Culture-specific care for Indigenous people: A primary health care perspective ill-informed and simplistic, but further hinders Aboriginal communities’ and health care providers’ collective efforts to address the problem, thereby reinforcing inappropriate stereotypes. Whether intentional or not, subtle and overt forms of racism exist in contemporary media. These include depictions that stereotype Indigenous Australians as living in discrete remote communities (Scrimgeour 2007; Johns 2006), the framing and reporting of news (Bannerjee & Osuri 2000), and in inappropriate comparisons with unrelated minority groups in other countries (Shaw 2000). We assert that this type of stereotyping is racist. In general, mainstream nurse researchers have failed to confront racism as an issue that has become conflated with culture (Anderson et al 2003; Barnes et al 2003; Culley 2006; Gustafson 2005; O’Brien 2006). Racism in any form denotes certain groups as being uncivilised, inferior, and having cultural traits that are linked to their physical appearance. It postulates practices that differentiate, exclude, alienate and dominate (Culley 2006). In the health care system this can include direct psychological or physical violence, exclusionary practices, unhealthy symptoms or institutional practices that deny access to adequate or appropriate care (Culley 2006). The cause of this type of bias often lies in health professionals’ approach to assessing and analysing health problems. Using existing inventories to assess problems can lead to defining Indigenous people according to norms established in the non-Indigenous population (Puzan 2003;Ten Fingers 2005). It is also illustrated when health professionals mistake social and health problems for cultural characteristics, or ignore inequities in the health care system that lead to under-servicing in the hospital system compared with equally ill nonIndigenous patients (AMA 2007; Browne 2005). This runs the risk of disempowerment, where predominant discourses and the way nonIndigenous health professionals approach Indigenous health create a feeling of powerlessness and
CN
disengagement from cultural life as well as health care (Durie 2004; Eckermann et al 2006). Many Indigenous people are also disadvantaged in Australia’s health system through the conflict between efficiency and equity. This occurs when medical doctors or administrators try to prioritise care or inclusion in treatment schedules on the basis of low-risk interventions or stereotypical expectations, especially for Indigenous people who have multiple risks that exclude them from treatments (AMA 2007). Another problem occurs when Indigenous people refuse treatment, which may be dismissed by health professionals as cultural. In fact, many refusals are due to a lack of appropriate communication or language barriers (AMA 2007). Indigenous people may also be discriminated against because of homelessness, or because family structures are not recognised by the system that allocates payments or co-payments on the Medical or Pharmaceutical Benefits Schemes (AMA 2007). For example, consent for the treatment of minors often does not allow for Indigenous kinship structures where care, responsibility and decision-making for children can rest with extended family, in addition to that of biological parents or legal guardians, particularly when parents might be ill or not able to care for their children. These kinship systems are important to maintaining social organisation in many Indigenous communities, which further illustrate the need for flexible, culturally-inclusive approaches to Indigenous health. The Australian Indigenous Doctors Association (AIDA) (2007), the AMA (2007) and the Council of Aboriginal and Torres Strait Islander Nurses (CATSIN) (2007) have recently launched attempts at moving the institutionalised racism of Australia’s health care system to the forefront of public discussion.They, along with a small number of nurse researchers (Anderson et al 2003; Barnes et al 2000), advocate the need to make explicit the interactions between culture and other aspects of care in the clinical
Volume 28, Issue 1–2, April 2008
CN
169
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:41 PM
Page 170
Anne McMurray and Rani Param
context (AIDA 2007). AIDA (2007) recommends a five-pronged approach for the health care system in terms of attitudes, structures, policies and services.These include: • valuing diversity; • developing a capacity for cultural self-assessment; • maintaining awareness of the dynamics inherent in the interactions between cultures; • institutionalising cultural knowledge; • adapting service delivery to reflect the understanding of diversity between and within cultures. The AMA and CATSIN also recommend including sensitivity to Indigenous cultures in medical and nursing education programs and accreditation of providers, and both groups have lobbied the Commonwealth government for additional resources to improve Indigenous health outcomes (AIDA 2007; AMA 2007).
IS CULTURE-SPECIFIC CARE POSSIBLE? The question of culture-specific care is contentious with respect to Indigenous Australians, especially in the absence of a single, uniform Indigenous Australian culture. Instead the focus should be on cultural relativism and breaking down the power relations that pervade clinical interactions. Cultural relativism is a reflection of the local partnership approach to care, which, within the tenets of primary health care is the most salient strategy for developing cultural competence. In this context, health providers are not always the dominant group, making decisions for rather than with another group (Gustafson 2005).Working as partners, while responding to identified needs for intervention, reflects an egalitarian approach to the health care situation. A partnership approach helps ensure that the diagnosis and plan for treatment includes culturally embedded input and decision-making in relation to how people maintain their health in the context of relation170
CN
Volume 28, Issue 1–2, April 2008
ships with the social and natural environment and the social order (Fisher 2006).This position disputes the contention that health care professionals provide culture-specific care. Rather, through egalitarian partnerships health professionals work with Indigenous people to plan culturally appropriate care.
CONCLUSION Clearly, there are a number of areas for change in both health care and Australian society.These include the following recommendations for change: • Create public recognition of the unique needs and sensitivities of Indigenous Australians. • Develop national policies to support the development of economic, social and cultural capital to foster self-determinism, including and strategies for culturally appropriate, sufficiently resourced education and skill development. • Identify culturally appropriate needs such as infrastructure and housing, to support Indigenous families within which children can grow safely, within their cultural, family and community groups. • Address inequities in service provision in terms of partnerships to help develop individual capacity and greater access and equity in health services. • Promote greater connectivity between Indigenous people and their advocates in health and social interactions, and cultural sensitivity in all health care practices. • Build Indigenous workforce capacity through national training plans, culturally safe employment strategies including interview and selection procedures, and ongoing skills and capacity development (Adelson 2005; Bramley et al 2005; CATSIN 2007; Pearson 2005; Ring & Brown 2003; Zubrick et al 2005). • Provide cultural awareness training in the treatment and management of specific condi-
CNJ 28_1_2_internal.qxd
14/07/2008
12:42 PM
Page 171
Culture-specific care for Indigenous people: A primary health care perspective
CN
tions among Indigenous people, including Australia’s Health 2004. Cat No AUS 44. cancer and chronic diseases (NHRA 2007). Canberra: AGPS. • Ensure health promotion programs and the Australian Medical Association (2007) Aboriginal and Torres Strait Islander Health: Institutionalised research that informs them includes authenInequity Not Just a Matter of Money. Report Card tic case studies of Indigenous people that illuSeries 2007. Canberra: AMA. minate the unique Indigenous experiences of life and of health care (Reimer-Kirkham 2002; Bannerjee SB and Osuri G (2000) Silences of the media: whiting out Aboriginality in making CATSIN 2007).These measures can help pronews and making history. Media, Culture and vide a basis for strength-based approaches Society 22(3): 263–284. to health promotion that validate cultural identities and capacities (Brough Bond & Hunt Barnes D, Craig K and Chambers K (2000) A review of the concept of culture in the holistic 2004; Reading, Ritchie, Victor & Wilson nursing literature. Journal of Holistic Nursing 2005). 18(3): 207–221. Browne A (2005) The sociopolitical context of References nurses’ encounters with First Nations women Adelman M, Erez E and Shalhoub-Kevorkian N in a Canadian health care setting. International (2003) Policing against minority women in Conference on innovations in Nursing. multicultural societies:‘Community’ and the Keynote Presentation. Fremantle Western politics of exclusion, Police and Society 7: Australia 12 November. 105–133. Brough M, Bond C and Hunt J (2004) Strong in Adelson N (2005) The embodiment of inequity: the City: towards a strength-based approach in Health disparities of Aboriginal Canada. CanadIndigenous health promotion. Health Promotion ian Journal of Public Health 96(S2): S45–S61. Journal of Australia 15(3): 215–220. Anderson J, Perry J, Blue C, Browne A, HenderCouncil of Aboriginal and Torres Strait Islander son A, Koushambbi B, Reimer Kirkham S, Nurses (2007). Professional issues. Accessed on Lynam J, Semiuk P and Smye V (2003) ‘Re13 June 2007 at www.indiginet.cm.au writing’ cultural safety within the postcolonial /catsin/professional_issues.html. and postnational feminist project. Advances in Culley L (2006) Transcending transculturalism? Nursing Science 26(3): 196–214. Race, ethnicity and health-care. Nursing Inquiry Astbury J, Atkinson, J, Duke, JE, Easteal, PL, 13(2): 144–153. Kurrie, SE,Tait, PR,Turner, J (2000) The Durie M (2004) An Indigenous model of health impact of domestic violence on individuals. promotion. Health Promotion Journal of Australia Medical Journal of Australia 173: 427–731. 15(30): 181–185. Australian Council for Aboriginal Reconciliation Eckermann A, Dowd T, Chong E, Nixon L, Gray (1994) Walking together: the first steps. Report of R and Johnson S (2006) Binan Goonj: Bridging the Australian Council for Reconciliation. Cultures in Aboriginal Health, 2nd edn. Sydney: Canberra: AGPS. Elsevier. Australian Indigenous Doctors Association Fisher R (2006) Congruence and functions of (2007) An introduction to cultural competency. personal and cultural values: Do my values Royal Australasian College of Physicians. reflect my culture’s values. Personality and Accessed at http://www.racp.edu.au/hpu Social Psychology 32(11): 1419–1431. /policy/indig_cultural_competence.htm on Gustafson D (2005) Transcultural nursing theory 23 January 2007. from a critical cultural perspective. Advances in Australian Institute of Health and Welfare (2004) Nursing Science 28(1): 2–16.
Volume 28, Issue 1–2, April 2008
CN
171
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:42 PM
Page 172
Anne McMurray and Rani Param
Hertzman C and Power C (2006) A life course approach to health and human development. In Heymann J, Hertzman C, Barer M and Evans R (Eds) Healthier societies: From analysis to action, pp 83–106. Oxford: Oxford University Press. Johns G (2006) Social Stability and Structural Adjustment, Bennelong Society 6th Annual Conference – Leaving Remote Communities. Accessed at www.bennelong.com.au/confer ences/pdf/Johns2006.pdf on 1 June 2007. McMurray A (2006) Community Health and Wellness:A Socio-ecological Approach, 3rd edn. Sydney: Elsevier. Mignone J and O’Neil J (2005) Social capital and youth suicide risk factors in First Nations Communities. Canadian Journal of Public Health 96 (S1): S51–S54. National Rural Health Alliance (2007). After forty years it’s time, Media Release, accessed on 26 May 2007 online at www.ruralhealth.org.au. O’Brien A (2006) Moving toward culturally sensitive services for Indigenous people: A non-Indigenous mental health nursing perspective. Contemporary Nurse 21(1): 22–31. Pearson N (2005)The CapeYork Agenda.Address to the National Press Club. Canberra, Nov. 30. Pomaika’I Cook B,Tarallo-Jensen L,Withy K and Berry S (2005) Changes in Kanaka maoli Men’s Roles and Health: Healing the Warrior Self. International Journal of Men’s Health 4(2): 115–130. Puzan E (2003) The unbearable whiteness of being (in nursing). Nursing Inquiry 10(3): 193–200. Reading J, Ritchie A,Victor C and Wilson E (2005) Implementing empowering health promotion programs for Aboriginal youth in two distinct communities in British Columbia, Canada. Promotion and Education X11(2): 62–65. Reimer Kirkham S and Anderson J (2002) Postcolonial nursing scholarship: From epistemology to method. Advances in Nursing Science 25(1): 1–17. 172
CN
Volume 28, Issue 1–2, April 2008
Sen A (1999) Development as freedom. New York: Alfred A. Knopf. Scrimgeour D (2007) Town or country: which is best for Australia’s Indigenous peoples? Medical Journal of Australia 186(10): 532–533. Shaw W (2000) Ways of Whiteness: Harlemising Sydney’s Aboriginal Redfern. Australian Geographical Studies 38(3): 291–305. Shore J and Spicer P (2004) A model for alcoholmediated violence in an Australian Aboriginal community. Social Science and Medicine 58: 2509–2521. Smith R (2003) Learning from Indigenous people. Editorial, British Medical Journal 327: 1. Ten Fingers K (2005) Rejecting, revitalizing, and reclaiming. Canadian Journal of Public Health 96(Suppl 1): S60–S63. Toussaint S (2003) ‘Our shame, blacks live poor, die young’. Indigenous health practice and ethical possibilities for reform. In Liamputtong P and Gardner H (Eds) Health, Social Change and Communities, pp 241–56. Melbourne: Oxford University Press. Trewin D and Madden R (2005) The Health and Welfare of Australia’s Aboriginal and Torres Strait Islander Peoples. Canberra: ABS Cat No 4704.0 AIHW Cat No IHW14. Whitehead M (2007) A typology of actions to tackle social inequalities in health. Journal of Epidemiology Community Health 61: 473–478. World Health Organization (2005) Action on the social determinants of health: Learning from previous experiences. A background paper prepared for the Commission on Social Determinants of Health, March. Geneva: WHO accessed on 6 June 2006 at http:// www.who/int/social_determinants/en/. Zubrick S, Silburn S, Lawrence D, Mitrou F, Dalby R, Blair E, Griffin J, Milroy H, de Maio J, Cox A and Li J (2005) The Western Australian Aboriginal Child Health Survey.The Social and Emotional well-being of Aboriginal Children and Young People. Perth: Curtin University of Technology and The Telethon Institute for Child Health Research.
CNJ 28_1_2_internal.qxd
14/07/2008
12:42 PM
Page 173
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 173–188.
The significance of a culturally appropriate health service for Indigenous Ma-ori women ABSTRACT
Key Words Ma- ori health; indigenous health; cultural safety; cultural competence; worldview; nursing
A culturally appropriate health service is contingent on the inclusion of client’s cultural beliefs and practices into intervention plans. Not establishing key cultural beliefs and practices risks providing a health service that lacks relevance and compromises its efficacy for its recipients. Anecdotally, cultural appropriateness and acceptability of health services is often lacking for Ma-ori women (Indigenous to Aotearoa New Zealand), hindering positive health experiences and outcomes.This paper explores an aspect of findings of research undertaken with Ma-ori women to discover what was important for their health and well-being, and their interactions with mainstream health services. Data from semi-structured interviews with 38 Ma-ori women was used to generate a Glaserian grounded theory informed by a Ma-ori-centred approach to explain the weaving of their health and well-being. It explains, in part, the importance of determining Ma-ori women’s cultural worldviews and practices when assessing and planning effective interventions. Cultural safety and cultural competence will be explored as vehicles to improve culturally appropriate and acceptable health care for Indigenous women. Received 6 August 2007
Accepted 19 March 2008
CN
the trust of clients who are Indigenous peoples, and extends beyond the establishment of relationships to respecting their worldviews and DENISE WILSON cultural preferences. Failure to identify key culSenior Lecturer in Nursing (Ma-ori Health) tural beliefs and practices, or the worldview of Massey University health, well-being, and illness risks providing Auckland, New Zealand and health care that lacks relevance and compromisFellow of the College of es its efficacy.When interventions ‘go wrong’ or Nurses outcomes are not achieved, it is not unusual for Aotearoa, New Zealand clients to be blamed and labelled ‘non-compliant’.This is a phenomena experienced by many INTRODUCTION ccessing culturally appropriate and accept- Ma-ori women (Indigenous to Aotearoa New able health services is vital for engendering Zealand) who are often subjected to victim
A
Volume 28, Issue 1–2, April 2008
CN
173
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:42 PM
Page 174
Denise Wilson
blaming, negative labels and racism, mistakenly reinforced by their under-utilisation of, and late presentation to, health services when they are unwell.This situation is similar to other Indigenous women in countries where they have been subject to colonisation (Baker & Daigle 2000; Browne & Fiske 2001; Dodgson & Struthers 2005), and is an approach that denies who they are and their unique health needs. Anecdotally, the cultural appropriateness and acceptability of health services and health care providers, such as nurses, is often found lacking by Ma-ori (Indigenous to Aotearoa New Zealand), compromising their access and use of health services (Reid and Robson 2006).The importance of culture and health is well established as a concept in nursing (CampichaBiacote 2002; Giger & Davidhizar 1999; Leininger 1985; Ramsden 1990; Wepa 2005), and McCloskey and Diers’ (2005) research into the New Zealand health reforms demonstrates that nursing is linked to the quality of client outcomes. In response to the importance of culture, safety and Indigenous concerns about the negative health experiences of Ma-ori, New Zealand nurses have been required to undergo cultural safety education, and demonstrate culturally safe practice since the early 1990s (Ramsden 1990). More recently, with the introduction of competency based practising certificates, they are required to demonstrate competency in culturally safe practice.This situation raises the question: How, when nurses, along with other health professionals, are educated in the importance of culture in health, and required to demonstrate competency in culturally safe practice do claims of culturally inappropriate and unacceptable experiences in mainstream health services still exist more than 15 years later? This paper will focus on an aspect of Glaserian grounded theory about the weaving of health and well-being by Ma-ori women. To begin, Ma-ori women’s health, and the place of culture in nursing, will be described as a back174
CN
Volume 28, Issue 1–2, April 2008
ground. This will be followed by a description of the research and an overview of the grounded theory generated. An analysis will be undertaken of the importance of nurses recognising and integrating important cultural beliefs and practices of Indigenous Ma-ori women into their health experiences to increase the likelihood of positive health outcomes.The value and efficacy of cultural safety will be critically explored within the contexts of first, the professional environment and then the regulated environment within Aotearoa New Zealand requiring nurses to demonstrate competency in culturally safe practice, using the research findings. The notion of cultural competence will be explored as a foundation for improving the delivery of culturally appropriate health care for Indigenous women, such as Ma-ori.
BACKGROUND
Ma-ori women, like many other women, hold important roles in maintaining the health of their children and wha-nau (immediate and extended family). They are referred to as the kaitiaki (guardians) of wha-nau health and wellbeing (Public Health Group 1997). However, Ma-ori experience inequalities in health status and health outcomes when compared to other groups within Aotearoa New Zealand. This is a similar situation for the Indigenous peoples of Australia, Canada, America and Hawaii (Anderson et al 2006), and is related to histories of colonisation that have contributed to their contemporary socioeconomic disadvantage, unhelpful stereotypes, and racism, all negatively impacting on the health of individuals and communities. Health determinants extend beyond genetics and disease processes to include factors such as socioeconomic deprivation, ethnicity and race, colonisation, and racism, all reasons for differential access and use of health services by Indigenous peoples (Ibrahim,Thomas & Fine 2003; Reid & Robson 2006). Socioeconomically, Ma-ori women are more likely to experience deprivation and have life
CNJ 28_1_2_internal.qxd
14/07/2008
12:42 PM
Page 175
The significance of a culturally appropriate health service for Indigenous Ma-ori women circumstances that reflect this.The level of deprivation they experience highlights significant inequalities that exist between Ma-ori and other peoples living in Aotearoa New Zealand, despite gradually declining mortality rates between 1980 and 1999 (Blakely et al 2004). Ma-ori women have a life expectancy of 73 years, nine years less than the 82 years experienced by nonMa-ori (Ministry of Health 2006).The five major causes of mortality (by numbers) for Ma-ori women are ischaemic heart disease, lung cancer, chronic obstructive pulmonary disease, cerebrovascular disease, and diabetes. Breast cancer is added to this list when years of life lost are considered, with Ma-ori women 1.3 times more likely than non-Ma-ori women to be diagnosed with, and twice as likely to die from breast cancer. Ma-ori women also experience adverse health effects of violence with an assault and homicide hospitalisation rate that is greater than five times than non-Ma-ori women. Despite a targeted campaign to improve access to screening and early intervention for cervical cancer, Ma-ori women are twice as likely to be diagnosed with cervical cancer, and four times as likely to die from it (Ministry of Health 2006).These examples are indicative of issues relating to their access and use of primary and secondary health services. Ma-ori, health care provider, and government concerns regarding these inequalities resulted in the identification of Ma-ori health as a national health priority in 2000 (King 2000). The 2002–2003 New Zealand Health Survey (Ministry of Health 2006) found that being unable to contact the doctor, having no transport, cost, time, difficulty with scheduling timely and suitable appointments, and either not wanting to make a fuss or being bothered were reasons cited for not seeing a general practitioner when needed. Indeed, the avoidable and amenable (relates to deaths from conditions responsive to health care) mortality rates and avoidable and ambulatory sensitive (conditions responsive to timely access to primary care services, preventing hospitalisation) hospitalisation rates are 2.5
CN
times and 1.5 times higher than non-Ma-ori, respectively (Ministry of Health 2006). Globally, Indigenous women with histories of colonisation have comparable experiences of mainstream health services, despite concepts of cultural safety, transcultural nursing care, and cultural competence being part of the nursing body of knowledge. The notion of culture in contemporary nursing practice has been evident since the introduction of transcultural nursing by Madeleine Leininger in the 1950s. Cultural safety was instigated in the 1990s in Aotearoa New Zealand in response to Indigenous Ma-ori concerns about the inequalities in their health status and the negative health service experiences they encountered in health care providers. A Ma- ori nursing student described this, within the context of safety in nursing, as a lack of ‘cultural safety’ to explain Ma-ori experiences where their cultural beliefs, practices and needs were neither acknowledged nor respected (Ramsden 2002). Culture is defined by Wepa (2005: 31) as: Our way of living is our culture. It is our taken-for-grantedness that determines and defines our culture. The way we brush our teeth, the way we bury people, the way we express ourselves through art, religion, eating habits, rituals, humour, science, law and sport; the way we celebrate occasions … is our culture. All these actions we carry out consciously and unconsciously. Simply, culture refers to the beliefs and practices people undertake daily, contributing to the way they view the world, and providing a point of reference for comprehending health, illness, life and death (Giger & Davidhizar 1999; Leininger 1978, 1685, 1988, 1996, 2001, 2006). Culture is dynamic, varies between and within groups, and changes in response to time and societal changes, and is evident in language. Leininger’s Culture Care Diversity and Universality theory requires nurses to deliver
Volume 28, Issue 1–2, April 2008
CN
175
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:42 PM
Page 176
Denise Wilson
culturally congruent nursing care to people through helpful acts toward, or for, them guided by the Sunrise Model (Leininger 1985). An underlying premise of transcultural nursing (informed by an anthropological perspective) is that cultural knowledge can be acquired about a range of different cultures. Transcultural nursing aims to improve client care, and offers a theory to predict and explain cultural information, through the formal education of nurses. A number of cultural competence frameworks arising out of transcultural nursing care exist to assess nurse’s practice.While transcultural nursing has been used internationally, nurses in Aotearoa New Zealand adopted the conceptual framework of cultural safety. Ramsden (1990) argued that the reality of gathering culturally specific knowledge about groups was problematic due to the variability that is present among and within groups. The evolution of cultural safety in Aotearoa New Zealand has been fraught and marked by public and political interference. Originally cultural safety was grounded in the Treaty of Waitangi and biculturalism, but over time has expanded to include cultural groups beyond ethnicity (Nursing Council of New Zealand 2005; Wepa 2005). Briefly, the Treaty of Waitangi is an agreement between Ma-ori and the British Crown that outlined their relationship, and guaranteed Ma-ori the right to self-determination, equal rights as British citizens, and protection. Ramsden (1990, 2002) argues that the worldviews of nurses and health services contrast with Ma-ori, thus requiring nurses to identify the key beliefs and practices for health and well-being of Ma-ori clients.To prepare nurses, cultural safety education requires nurses to initially examine their own cultural realities and attitudes, and how these and the power that they hold as nurses, can impact on those that they work with, and the development of relationships. One of the underlying premises of cultural safety is the recognition that diversity exists not 176
CN
Volume 28, Issue 1–2, April 2008
only between cultural groups but within them. Thus, the development of specific beliefs and practices for nurses to learn is resisted. The establishment of relationships with clients to elicit the cultural beliefs and practices that need to be respected and integrated into their health experience is essential. Consequently, it is the recipient of nursing care who determines whether a nurse’s practice is safe, not nurses (Nursing Council 2005). This is a weakness of cultural safety as it is generally nurses who make a judgement about whether a nurse’s practice is culturally safe or not.There is anecdotally a difficulty in freely ascertaining a client’s perspective of the care they received related to nurse–client power imbalances, their potential vulnerable status, and the likelihood of them needing to reuse a health service. Registered nurses in Aotearoa New Zealand, however, have been required to undergo education in cultural safety since the early 1990s, and demonstrate their competency. Registered nurses in Aotearoa New Zealand, however, have been required to undergo education in cultural safety since the early 1990s, and demonstrate their competence in this area. More recently, registered nurses along with other registered health professionals are required to demonstrate ongoing ‘cultural competence’ in accordance with section 118(iv) of the Health Practitioners Competence Assurance (HPCA) Act 2003 – legislation designed to protect the health and safety of members of the public.The requirements for demonstrating competence are a combination of meeting a prescribed minimum of practice and professional development hours, and demonstrating the Council’s competencies in the registered nurse’s area or context of practice. This process involves providing evidence generated from a combination of self-assessment, peer assessment or review, and assessment by a senior nurse. Guiding this process is the Nursing Council’s definition of cultural competence: ‘the combination of skills, knowledge, attitudes, values and abilities that underpin effec-
CNJ 28_1_2_internal.qxd
14/07/2008
12:42 PM
Page 177
The significance of a culturally appropriate health service for Indigenous Ma-ori women tive performance as a nurse’ (Nursing Council 2008). However, competency 1.5 requires nurses to ‘practise nursing in a manner that the client determines as culturally safe’, which by definition requires a judgement to be made by the recipients of care (Nursing Council 2005). Both transcultural nursing and cultural safety aim to ensure that nurses consider people’s cultural needs and that these are integrated into their nursing practice. The body literature and research demonstrating the efficacy of cultural safety, however, is limited with the majority of research focused on the efficacy of facets of cultural safety education (McEldowney et al 2006, Wepa 2003). Johnstone and Kanitsaki (2007), who researched its appropriateness for Australia by establishing Australian health care providers’ level of understanding, rightfully criticise the lack of research into the efficacy of cultural safety practice. However, Johnstone and Kanitsaki’s (2007) report has limitations, with a covert agenda to reinforce the inappropriateness of cultural safety for Australia apparent, along with a lack of key information on aspects of the research design and in the reporting of findings. Notably the importance of an educative process in the development of culturally safe practice was not acknowledged. The role of culture in health and well-being, and its significance for nurses and other health care providers is well established. Culturally appropriate services are fundamental for improving the access and use of services by Ma-ori women (Wilson 2004). But the notion of being knowledgeable about Maori culture is fraught and not always possible – Ma-ori were not a homogenous group pre-colonisation, and great diversity in beliefs and practice is evident in contemporary Ma-ori.The development of meaningful relationships with Ma-ori women that respect and value their cultural beliefs and practices is crucial to meeting their health needs. Such an approach minimises the impact of Ma-ori women being caught between health care providers delivering services informed by a biomedical
CN
worldview, and their own unique worldview and life circumstances. A paucity of research into Ma-ori women’s interactions with mainstream health services exists. Given the key role Ma-ori women have in caring for their wha-nau and in the transmission of health information it is important to gain an insight and understanding of their perspectives on health and illness, and the influences of their culture on their health behaviours. Such information can then provide insight and inform the practices of nurses and other health care providers.
RESEARCH
The research aimed to explore Ma-ori womens’ understanding of health, and their interactions with mainstream health services guided by the question, What is happening for Ma-ori women, their health, and their interactions with ‘mainstream’ health services? Ethical approval for the research was obtained from the Massey University Human Ethics Committee and the Bay of Plenty Ethics Committee.
Methodology Ma-ori have a history of being subjected to negative research processes and outcomes (not dissimilar to other Indigenous peoples) (Sporle 2003). Therefore, it was imperative that the research methodology and approach selected enabled the values, beliefs and traditions of Ma-ori women to be respected. This decision was guided by Smith’s (1999) assertion that there is little benefit in perpetuating disrespectful research processes and negative stereotypes, and interpreting findings through the prevailing dominant cultural lens, or romanticising ‘desirable’ aspects of Ma-ori culture. A Ma-ori centred approach described by Durie (1997) provided a blueprint to develop a research process to ensure Ma-ori values and processes informed it, beginning with initial consultation and forming the question to align the research with Ma- ori aspirations, to disseminating the findings through consultation processes.The underlying assumpVolume 28, Issue 1–2, April 2008
CN
177
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:42 PM
Page 178
Denise Wilson
tions of the Ma-ori-centred approach used were, that: 1. The research should be beneficial to Ma-ori women. 2. Many Ma-ori women integrate a holistic worldview into their everyday lives. 3. The lives of Ma-ori women involve multiple and complex interactions, reflective of the various roles they hold within a bicultural society. 4. Ma-ori should have the opportunity to maintain control through processes of consultation and participation throughout the research process in order to protect their cultural interests. The Ma-ori centred principles of whakapiki tangata (enablement), whakatuia (integration), and mana Ma-ori (control) described by Durie (1997) informed the research process. Pragmatically, this translated into Ma- ori women being actively involved in advising the development of the research question, and the process of meeting and working with participants was based on Ma-ori values and practices, such as sharing food and establishing mutual connections with places and people. A Ma-ori-centred approach ensured the research was culturally responsive and appropriate, and crucial in gaining ethical approval for research with Ma-ori. To explicate the research, the inductive nature of Glaserian grounded theory both philosophically and practically lent itself to being informed by a Ma-ori centred approach. Eliciting the interpretations and experiences Ma-ori women had about their health and interactions with mainstream health services was essential, and the inductive nature of Glaserian grounded theory enabled discovering the main concerns for Ma-ori women about health and mainstream service use. As Glaser (1999: 840) claims, ‘Grounded theory is what is [sic], not what should, could, or ought to be’. 178
CN
Volume 28, Issue 1–2, April 2008
METHOD Participants Thirty-eight women who identified as Ma-ori aged between 24 to 61 years were initially recruited using a purposeful network sampling strategy (Polit & Hungler 1991), and as the study progressed theoretically sampling was used. Participant selection was a collaborative endeavour with two Ma-ori women advisors, known within the Ma-ori community, actively involved in the development of the research design. Aided by a sound understanding of the selection criteria and the processes of theoretical sampling, these women also assisted in approaching potential participants, and negotiating the nature of their involvement in the study and their availability for an interview.Their strength was in being known within the community and being able to determine, what Morse (1991) terms as,‘insiders’ and ‘outsiders’. The Ma-ori women participating in the study came from mixed backgrounds.They lived in a variety of relationships (permanent, non-permanent and alone) and the majority had children, with many living in homes with more than one family or generation.Their educational backgrounds varied considerably along a continuum with some having no school qualifications to those who had completed tertiary level study. While most of the women were in paid work, the majority were in part-time employment, with some unemployed receiving statefunded income support. Not all women had access to telephones or private transport. If unwell, the women generally sought advice from either a medical practitioner or Ma- ori health provider (a health service delivered within a Ma-ori philosophy and provided by Ma- ori health professionals, such as nurses).
Data collection and analysis Semi-structured interviews with individuals and groups (dependent upon their choice and congruent with a Ma-ori centred approach) were
CNJ 28_1_2_internal.qxd
14/07/2008
12:42 PM
Page 179
The significance of a culturally appropriate health service for Indigenous Ma-ori women undertaken with the Ma-ori women. To elicit their understanding and experiences and to minimise researcher bias, Schreiber (2001) suggested the interviews be guided by broad questions, such as: • Tell me what does health mean to you? • What are the things that are important for your health? • Tell me about your experience with health services and the people working in them. The interview questions were designed to enable issues to be explored as they arose, and areas for theoretical sampling to be identified. Data was collected with detailed field notes and a reflective journal (Glaser 1998). Data collection occurred simultaneously with data analysis (Glaser & Strauss 1967) using constant comparative analysis to generate codes, emerging concepts and categories. These were verified and refined until saturation was reached – that is, when no new information could be added to a concept or category (Glaser 1978). Theoretical sampling purposefully guided data collection, including the exploration, clarification, verification, and saturation of the emerging codes, concepts and categories (Glaser 1998). As properties emerged and codes were refined into concepts and categories, these were sorted and re-sorted. Coding was confined to the substantive area under study to promote the relevance, fit and work of emerging categories.The development of the ideas and emerging meaning were captured by recording of memos that also assisted in tracking the conceptualisation of codes, concepts, categories and their relationships and the basic social psychological process (BSPP) of weaving. Glaser’s (1978) criteria of fit, relevance, work and modifiability were used to establish the rigour of the study.The ‘fit’ was established through a systematic reviewing of the processes for generating codes, categories, and conceptualisation of the data to confirm that these and the BSPP of weaving were the concerns of the
CN
Ma-ori women.The ‘relevance’ and ‘work’ of the grounded theory (Glaser 1978) was confirmed its ability to explain, predict and interpret the substantive area of Ma-ori womens’ health and their interaction with health services. This was demonstrated by a Ma-ori woman saying the following about the grounded theory produced: Your observations are truly accurate and I am blown away by what I consider to be deeply insightful comments … I just wanted to share how moved I’ve been reading your paper! (E-mail correspondence JM) The grounded theory generated is dynamic and responsive to the societal and environmental changes impacting on Ma-ori women, and has the potential to be ‘modifiable’. It is expected that the BSPP of weaving would remain without variation.
NGA- KAIRARANGA ORANGA – THE WEAVERS OF HEALTH AND WELL-BEING
‘Nga- Kairaranga Oranga – The Weavers of Health and Well-being’ is the substantive grounded theory that explains the health and well-being of Ma-ori women. It provides a conceptual insight into what Ma-ori women had about their health and well-being, and their interactions with ‘mainstream’ health services and health care providers. ‘The Weavers of Health and Well-being’ comprises three core categories: ‘Mana Wa-hine’ (the prestige and status of Ma-ori women), ‘The Way It Is’, and ‘Engaging with Health Services’ and the basic social psychological process (BSPP) of weaving that integrates the numerous dimensions that determines health and well-being.The position a Ma-ori woman has in the world, along with influences such as age, wisdom, resources and life circumstances all affect the weaving of their health and well-being. The process of weaving health and well-being is a unique lifelong process for each Ma-ori woman, and illustrates how the core categories and their
Volume 28, Issue 1–2, April 2008
CN
179
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:42 PM
Page 180
Denise Wilson
dimensions are complexly and diversely woven together. The outcome of the weaving of health and well-being, that is optimal or less than optimal is dependent upon the strength, the continuity and the endurance of the weaving of health and well-being.
Mana Wa-hine The first core category, ‘Mana Wa-hine’, explains the important components for the health and well-being of Ma-ori women, such as wha- nau (family), spirituality, traditional and contemporary knowledge, and self-care behaviours. This category outlines areas that health care providers should explore by eliciting their view of health and well-being to ensure the cultural integrity of a Ma-ori woman is maintained what is important for their health and well-being. Way it is ‘The Way It Is’, is the second core category that explains the challenges and barriers Ma-ori women have to experience positive health outcomes.These challenges and barriers may either originate from the women themselves or past experiences of health services they have interacted with directly or vicariously through wha-nau and friends. Challenges and barriers involve a strong socialisation to put others first, fears and past health experiences, particularly relating to deaths of wha-nau members, and negative encounters with health care providers. This category provides an indication as to what prevents Ma-ori women from accessing health services in a timely manner. Engaging with health services The final core category, ‘Engaging with Health Services’, explains the needs of Ma-ori women, based on both positive and negative experiences, when they interact with health services and health care providers. The ability of Ma-ori women to develop positive relationships with health care providers either promotes or impedes connecting and relating, enabling the 180
CN
Volume 28, Issue 1–2, April 2008
access and use of relevant health services. Influencing access to services, connecting with an appropriate service and forming effective relationships, weave together to determine the nature of engagement a Ma-ori woman has with a health service, and its health care providers. The quality of information shared, feelings of comfort and interpersonal relationships are indicative of effective relationships, but these are counteracted by Ma-ori women’s hypersensitivity to negative and judgmental attitudes of health care providers.
IMPORTANCE OF CULTURALLY APPROPRIATE HEALTH SERVICES Of note, the Ma-ori women in this research consistently encountered health services and health care providers that were problem-focused, who compartmentalized their health issues or problems that resulted in their needs not being recognised and planned interventions being inappropriate. Adopting a predominately problem-based, biomedical focus neglects not only the specific needs of each Ma-ori woman, but also the socio-cultural dimensions that impact on health and well-being. This can increase the likelihood of being recipients of victim blaming or deficit explanations when health care providers determine outcomes that are not achieved, the responsibility being placed on individual Ma-ori women and their wha-nau. This research reinforces the need for culturally appropriate and acceptable interventions and health care providers, such as nurses, are vital for improving access, use, and ongoing use by Ma-ori women, especially for long-term health issues. However, without meaningful relationships with Ma- ori women their specific needs or factors necessary to achieve positive health outcomes will be overlooked, or recognising some are beyond their immediate control, such as socioeconomic circumstances. Continued access and use of health services is dependent upon, and optimized by the development of effective relationships with nurses and
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 181
The significance of a culturally appropriate health service for Indigenous Ma-ori women other health care providers – a powerful indicator of the nature of future access and use of health services. Understanding how Ma-ori women ‘weave’ their health and well-being can positively inform the practise of ‘mainstream’ health care providers, such as nurses. ‘The Weavers of Health and Well-being’ illustrates the important aspects for Ma-ori womens’ health and wellbeing, along with the barriers and challenges to, and factors that facilitate, accessing and using health services. Acknowledging cultural beliefs ,and practices are a crucial link to facilitating optimal health outcomes, even for those women who had not been raised in ‘traditional’ Ma- ori ways, illustrated by the following: Not all Ma- ori women have been taught the ‘old ways’ and Ma- ori culture had been suppressed, but it was knowing you were Ma-ori – it was who one was. (Interview 4) Fundamental to a culturally appropriate health service is the determination of a Ma-ori woman’s key beliefs and practices for her health and wellbeing that need to be recognised, respected and integrated into her health experience, especially plans for interventions. Diversity exists between and within cultural groups leading to multiple and diverse worldviews – while there may be similarities, there are important differences for each woman.Thus, meaningful and genuine dialogue with Ma-ori women is crucial, along with a respect of their beliefs and practices, and a willingness to include important cultural practices that vary from those promoted by the ‘mainstream’ health services. Determining a Ma-ori woman’s beliefs and worldview is premised by the notion that different pathways that can be taken to reach an intended outcome. There needs to be a flexible approach together with a wider scope of who and how a service is provided to achieve the right person and right service. In other words there
CN
needs to be flexibility to do things outside of the traditional way in which health services are provided. (Interview 2) It is the cultural component that makes it different for Ma-ori women. (Interview 5) Ma-ori women are no strangers to walking in two worlds (Ihimaera 1998), but personal worldviews should not be automatically subjugated when they move from the world of Ma-ori to that of mainstream health services. Sibthrope, Anderson and Cunningham (2001) stress the domination of one worldview over others is problematic, especially when the role of culture is not considered in the development of health behaviours. For example, while an individual Ma-ori woman may be the focus of the attention of a nurse, her identity and possibly health issues may well be constructed within a collective context that includes wha-nau or hap? (a group of wha-nau with a common ancestor). Often when their health beliefs and practices challenge those of ‘mainstream’ health services, poor health outcomes are attributed to some deficit in the Ma-ori woman, as previously mentioned. Such explanations ignore health system deficits related to the delivery of services are not being addressed, such as not identifying cultural beliefs and practices. Acknowledging cultural beliefs and practices enables the holistic and spiritual dimensions many Ma-ori women have to be recognised, that usually contrast with western middle-class values and the biomedical view of health and illness (Mizrachi, Shuval and Gross 2005; Samson 1999). The beliefs and worldviews of Ma-ori women may contrast with those of nurses creating tension and conflict, compounded by a lack of understanding the historical and socio-political context for Ma-ori.The diverse experiences and influences Ma-ori are exposed to, highlights the need for nurses to reject adopting a universal approach to service delivery, outside of acute interventions needed for acute lifesaving inter-
Volume 28, Issue 1–2, April 2008
CN
181
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 182
Denise Wilson
ventions. Universal approaches to health care delivery are based on the notion that all users of health services, including Ma-ori, are treated the same, have similar health needs and can be generally approached in similar ways. Such practices are no longer acceptable or appropriate, although some Ma- ori women noted how a change toward universal approaches missed their culturally related needs: Nurses used to do ‘things’, but they do not do these now.The ‘things’, such as old values and practices, contribute to spiritual wellbeing. (Interview 4)
DISCUSSION Identifying and respecting the beliefs and worldviews of Ma-ori women is essential to improve timely access and use health services. Paraha (cited in Moir 1994:9) highlights the importance of acknowledging and respecting the realities of Ma-ori women, stating:‘At the bottom of each social pile I met Indigenous women, marginalised by a colonising power, who were fighting for their identity.’ The non-recognition of Ma-ori womens’ health needs, constructed within their socio-cultural reality denies their identity. Participants reported culturally based health needs were generally overlooked, and indicated the existence of cultural dissonance. Ma-ori persist in calling for culturally appropriate services (Durie 1998d; Reid et al 2000) maintaining issues underlying Ma-ori health status (in addition to factors such as socioeconomic determinants of health) are reflective of culturally unacceptable and inappropriate services. A growing body of literature (Bophal 2001; Browne & Fiske 2001; Eliason 1999; Jones 1999; Karlsen & Nazroo 2002; Kirchheimer 2003; McKenzie 2003; Reid et al 2000; Reid & Robson, 2006) points to a detrimental connection between health disparities and personal and institutional racism, and associated discriminating practices. Bophal (2001:1504) maintains that: ‘Racism is the most disturbing of the 182
CN
Volume 28, Issue 1–2, April 2008
potential explanations for … [health] inequalities.’ As racism is communicated through attitudes, behaviours and language, it necessitates nurses to undertake the process of self reflection and explore the negative impact attitudes and behaviours may have on Ma- ori women. Karlsen and Nazroo (2002), Kirchheimer (2003) and McKenzie (2003) all suggest racism is a public health issue. Failure to address personal and institutional racism within a health service perpetuates the complicity by health care providers in maintaining racism. Contemporary language and behaviours shrouded in political correctness that serves to make contentious issues more palatable, negates the realities that ‘others’, like Ma-ori women, may experience. Not acknowledging and addressing the negative effects of racism could be considered a failure in the duty to care and does little to facilitate the engagement of Ma-ori women in health services.
VALUE AND EFFICACY OF CULTURAL SAFETY Given that registered nurses have been educationally prepared in cultural safety since the early 1990s, it is somewhat concerning that Ma-ori women participating in this research report their cultural beliefs and practices are routinely not ascertained by nurses. Culturally safe practice requires nurses to: (a) Examine their personal cultural beliefs and values and how these may impact on their practice with people from an different culture, along with the power differentials that may exist; and (b) Recognise and respect of the beliefs and practices of health consumers, and incorporate these into intervention and treatment plans. (Nursing Council of NZ 2005; Ramsden 2002)
If improvements are to be made in the health status of Ma-ori women, nurses must continue to engage in a process of reflection on their practice that aims to increase their effectiveness
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 183
The significance of a culturally appropriate health service for Indigenous Ma-ori women in delivering culturally appropriate and acceptable health services – a strength of cultural safety. Such a process would involve reflecting on the interactions they have with Ma- ori women and how well their needs are determined and met in order to evaluate the efficacy of the interaction(s). Part of this process should also include a critique of the degree the nurse’ personal and professional cultural values and beliefs have facilitated or impeded the achievement of outcomes for a Ma- ori woman. Developing insight about the efficacy of one’s nursing practice is an important step in delivering culturally appropriate and acceptable health services. Since the implementation of legislation, registered health professionals are required to demonstrate competency to practice, cultural safety being one area the Nursing Council of New Zealand (The Nursing Council) requires registered nurse to demonstrate competency. Therein lies a fundamental problem in assessing nurses’ practise is culturally safe, as it is the recipient of nursing practice not the Nursing Council who determines whether a nurse’s practice is culturally safe or not (Nursing Council 2005). Despite the Nursing Council (2005) guidelines for cultural safety providing measures to assess practice none of these involve obtaining direct client feedback. Obtaining accurate client feedback is potentially problematic and at risk of the Hawthorne effect (Burns and Grove 1993), especially when Ma-ori women are reticent to create problems that may negatively affect any future health experiences by making a negative judgment about a nurse’s practice. But as ‘outsiders’, nurses are unable to make accurate judgements about whether a colleague’s practice is culturally safe. Nonetheless, nurses frequently judge their own and their colleague’s practice as ‘culturally’ safe while the recipients of the care, such as the Ma-ori women, may have differing perceptions but feel unable to articulate feelings of dissatisfaction. Often they endure a negative experience not to return again. Speaking out was generally not
CN
considered an option for Ma- ori women, with participants stating simply: The attitudes of health care providers are bad. (Interview 1) Complaining is not an option as things may get worse. (Interview 6) This situation lends weight to Johnstone and Kanitsaki’s (2007) views on the limitations of cultural safety. In addition to clinical expertise, the credibility of health care providers is a reflection of their efficacy and can influence the success of interventions and possibly health outcomes for Ma-ori women accessing and using health services. Attitudes and behaviours, in addition to the beliefs and stereotypes held by nurses, influence the nature of the relationships with Ma-ori women. Positive health experiences stem from meaningful partnerships established between nurses and clients, and influence the efficacy of health care providers. In such partnerships, nurses bring health and illness expertise, while Ma-ori women bring the knowledge about their health beliefs and practices, and life circumstances. Christensen (1990) asserts the notion of client as ‘expert’ is crucial to nurses’ practice, and for engendering trust and credibility. Table 1 outlines questions nurses can use to optimise culturally appropriate practice. Papps (2002) maintains that cultural safety education aims to address issues, such as racism, by increasing insight into stereotyped beliefs and assumptions held about Ma- ori seeking health services, and the impact these have on the delivery of services.The intention of cultural safety education is to improve outcomes by developing the efficacy of nurses working with Ma-ori, and other cultural groups (Ramsden 1990, 2002), nevertheless the reality that all clients have a culturally safe experience questionable. Universal approaches to practice deny clients their identity, and as Reid and Robson
Volume 28, Issue 1–2, April 2008
CN
183
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 184
Denise Wilson
TABLE 1: QUESTIONS
TO OPTIMISE CULTURALLY APPROPRIATE PRACTICE
Maintaining the Mana (status) and integrity of Ma-ori women • How are the key beliefs and practices (worldview) of Ma-ori women determined? • How are the principles of partnership, participation, and protection implemented when working with Ma-ori women? • What opportunities are enabled to undertake cultural practices that are important for a Ma-ori woman’s well-being? • How are life-circumstances relevant to health, identified and incorporated into the assessment and intervention plans? • How are barriers to the (a) access, and (b) use of a health service identified? • What barriers to the access and use of health services can nurses either minimise or remove? Promoting trust in the service What are the beliefs that I, as a nurse, personally hold about Ma-ori (Indigenous) women and their health? How can these beliefs potentially, or actually, impact on those I work with? What knowledge or practice frameworks guide working ‘with’ Ma-ori women? What knowledge and skills are required to develop my practice for working with Ma-ori women? Are my attitudes and behaviours toward Ma-ori women genuine and non-judgmental? If not, why? Does the health service have policies and processes that aim to improve the delivery of services to Ma-ori, and include the implementation of beliefs and practices of Ma-ori? • Are Ma-ori frameworks of health and services evident in the delivery of my nursing practice, or the health service?
• • • • • •
Facilitating access and use of a health service • What mode of communication is used to contact Ma-ori women about appointments, admissions, etc? Are there more effective ways that could be used? • Is the language used, ‘user-friendly’ and contain minimal or no jargon? • How are Ma-ori women greeted and welcomed to the service? • What Ma-ori images, language, etc are present in the physical environment of the health service to make it more inviting? • What choices do Ma-ori women have about how and when they access and use a health service? How are these choices communicated to Ma-ori women? Building on existing strengths • • • • •
What existing knowledge does a Ma-ori woman have about her current health status? What self-care and health promoting behaviours does this Ma-ori woman undertake? Has this Ma-ori woman undertaken any recent changes in lifestyle or self-care activities? What support systems does this Ma-ori woman have? How are these accessed? What additional knowledge and skills does this Ma-ori woman require to support her self-care activities?
Converging worldviews • How are the beliefs and practices of Ma-ori women, integrated into treatment and intervention plans? • How are the needs, outcomes, or goals of Ma-ori women identified? What support is required to achieve the outcomes for each Ma-ori woman? • What processes exist to include the wha-nau (immediate and extended family) of Ma-ori women in their health experiences, if they so wish?
184
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 185
The significance of a culturally appropriate health service for Indigenous Ma-ori women (2006:22) contend: ‘This obsession with “treating everyone the same” comes without acknowledgement of the need to treat people differently to achieve equal outcomes.’Yet, ‘The Weavers of Health and Well-being’ highlight negative experiences where Ma-ori women consistently felt their needs were not identified, and meaningful relationships not established.
CULTURAL COMPETENCE Campinha-Bacote (2002) and Rosenjack Burchum (2002) both stress that cultural competence is a lifelong process rather than a definitive endpoint, and while cultural safety is also a constant process, it polarises each nursing interaction into safe or unsafe according to Polaschek (1998). Cooper Braithwaite’s (2005) evaluative study links cultural competence with the achievement of improved outcomes and found that education improves competency. However, the differing understandings of cultural competence present challenges in terms of accurately and reliably capturing its meaning, making its measurement problematic (Geron 2002; Rosenjack Burchum 2002). Geron (2002) also questioned the accuracy of measuring cultural competence based on health care providers self-report without client input, and based on self-report is open to manipulation to accomplish a favourable outcome. Measuring practice competency is more than assessing technical or psychomotor competency, and includes the nurse’s attitudinal and behavioural capability to incorporate knowledge and skills to ensure a client’s cultural dimension is integrated into their health experience. Rosenjack Burchum (2002) found that the notion of cultural competence frequently includes the delivery of culturally specific information. However, the acquirement of culturally specific information does not acknowledge that diversity that exists between, and within cultural groups, such as Ma-ori, and is the antithesis of culturally safe practice within the Aotearoa New Zealand context.
CN
Durie (2001) maintains that cultural competency is less about behaving correctly, and more about practising in a sound manner. He goes further, citing the need to develop the concept of cultural safety (that focuses on the recipient’s experience) and proposes cultural competence to shift the focus on assessment onto the health care provider’s capability to deliver culturally safe practice. While attempts to measure cultural safety competency are generally devoid of client input, the notion of cultural competence proposed by Durie (2001) provides other dimensions that can be used for assessment. Based on Durie’s (2001b) work, the crux of cultural competency comprises: 1. The nurse (knowledge, beliefs, attitudes, power dimensions); 2. The nurse’s actions that improve a client’s health status; and 3. The ability to integrate a client’s culture into clinical practice. Cultural competence, therefore, is defined as the capability of nurse to articulate and demonstrate culturally appropriate and acceptable health services where clients feel culturally safe, and that reflecting the nurse’s reflexivity, knowledge, and skills, and an ability to work meaningfully with clients to meet their unique health and cultural needs during their health experience. ‘The Weavers of Health and Wellbeing’ informs criteria to measure a nurse’s competence through education and the capability to deliver a culturally appropriate and acceptable health service when working with Ma- ori women. Table 2 outlines criteria under the headings the nurse, actions aimed to improve health status, and integrating cultural beliefs and practices into clinical practice, demonstrating culturally competent practice. Effective preparation of nurses in these areas contributes to their making a difference in the health status of Ma- ori women. The cultural competency model proposed provides a plat-
Volume 28, Issue 1–2, April 2008
CN
185
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 186
Denise Wilson
TABLE 2: COMPETENCE
OF A HEALTH CARE PROVIDER ’ S CAPABILITY TO DELIVER A CULTURALLY APPROPRIATE AND ACCEPTABLE SERVICE
FOCUS AREA OF COMPETENCE 1. The nurse
COMPETENT ACTION • Articulates knowledge, and an analysis of Ma-ori women’s health, and the historical, socioeconomic, and political influences on their health status. • Identifies beliefs and attitudes held about Ma-ori women, and how these may impact on practice through a reflexive process. • Identifies the power the nurse holds and its potential impact on the health experience and health outcomes of Ma-ori women. • Demonstrates sound interpersonal communication skills necessary to establish meaningful relationships based on respect with Ma-ori women. • Discusses the significance of the Treaty of Waitangi and its application to health.
2. Actions of nurse • Assesses and communicates in a manner that is respectful, clear, and direct. aimed to improve • Involves the Ma-ori woman in the assessment, planning and decision making phases the client’s health of her health experience. status • Determines necessary support person(s) and/or advocate. • Determines the understanding a Ma-ori woman has of: (a) Health, wellness, ill-health, and illness. (b) Why she is accessing and/or using the health service. • Identifies cultural beliefs and practices that a Ma-ori woman needs observed while interacting with the health service. 3. Nurse’s ability to integrate a client’s culture into clinical practice
• Explains why information about key (cultural) beliefs and practices is being collected. • Integrates cultural beliefs and practices into the Ma-ori woman’s health experience, as appropriate. • Incorporates beliefs and practices into the Ma-ori woman’s intervention plan. • Evaluates the appropriateness and effectiveness of interventions with a Ma-ori woman.
form for reflecting upon previous interactions with Ma-ori women, and how such interactions could be improved and managed more effectively.
CONCLUSION
were frequently not recognised and devalued by ‘mainstream’ health care providers, and generally not included as part of their health care experience.While preparation of nurses in cultural safety and competence is essential in terms of its reflexive nature, its measurement is problematic. The evolution of cultural safety to include a framework to develop and assess cultural competency is timely. It offers a way of reducing the dissonance between nurses’ and Ma-ori womens’ perceptions of a nurse’s practice, and their practice to be better assessed.
Ma-ori women using ‘mainstream’ health services should rightfully expect that their cultural beliefs and practices will be respected, at a minimum. The importance of culture has been professionally recognised for several decades in nursing, and in Aotearoa New Zealand has been References a regulated feature of nurses’ practice since the Anderson I, Crengle S, Leialoha Kamaka M, Chen 1990s. When this expectation is not met, the T, Palafax N and Jackson-Pulver L (2006) experience can be unpleasant, and difficult, and Indigenous health in Australia, New Zealand risks compromising access and use of health and the Pacific, The Lancet 367: 1775–1785. services. The Ma-ori women in this research Baker C and Daigle MC (2000) Cross-cultural hospital care as experienced by Mi’kmaq reported feeling that their beliefs and practices 186
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 187
The significance of a culturally appropriate health service for Indigenous Ma-ori women clients, Western Journal of Nursing Research 22: 8–28. Blakely T, Ajwani S, Robson B,Tobias M and Bonne M (2004) Decades of disparity:Widening ethnic mortality gaps from 1980 to 1999, New Zealand Medial Journal 117: 995–1015. Bophal R (2001) Racism in medicine, British Medical Journal 322: 1503–1504. Browne AJ and Fiske J (2001) First Nations women’s encounters with mainstream health care services, Western Journal of Nursing Research 23: 126–147. Burns N and Grove SK (1993) The Practice of Nursing Research: Conduct, Critique & Utilization, 2nd edn,WB Saunders, Philapdelphia PA. Campinha-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: A model of care, Journal of Transcultural Nursing 13: 181–184. Christensen J (1990) Nursing Partnership:A Model for Nursing Practice. Daphne Brassell Associates, Wellington, NZ. Dodgson JE and Struthers R (2005) Indigenous women’s voices: Marginalization and health, Journal of Transcultural Nursing 16: 339–346. Durie M (1998) Whaiora: Maori Health Development, 2nd edn, Oxford University Press, Auckland, New Zealand. Durie M (2001) Cultural competence and medical practice in New Zealand. Paper presented to the Australian and New Zealand Boards and Council Conference,Wellington, New Zealand. Durie MH (1997) Identity, access and Maori advancement: in The Indigenous Future: Edited Proceedings of the New Zealand Educational Administration Society Research Conference, pp 1–15. Auckland Institute of Technology, Auckland, New Zealand. Eliason MJ (1999) Nursing’s role in racism and African American women’s health. Health Care forWomen International 20: 209–219. Geron SM (2002) Cultural competency: How is it measured? Does it make a difference? Generations 26: 39–45. Giger JN and Davidhizar RE (1999) Transcultural Nursing:Assessment and Intervention, 3rd edn, CV Mosby, St Louis MO. Glaser BG (1978) Theoretical Sensitivity, Sociology Press, Mill Valley CA.
CN
Glaser BG (1998) Doing Grounded Theory: Issues and Discussions, Sociology Press, Mill Valley, CA. Glaser BG (1999) The future of grounded theory, Qualitative Health Research 9: 836–845. Glaser BG and Straus AL (1967) The Discovery of Grounded Theory: Strategies for Qualitative Research Aldine Publishing, New York. Ibrahim SA,Thomas SB and Fine MJ (2003) Achieving health equity: An incremental journey, American Journal of Public Health 92: 1619–1621. Ihimaera W (ed) (1998) Growing up Ma- ori,Tandem Press, Auckland, New Zealand. Johnstone M-J and Kanitsaki O (2007) An exploration of the notion and nature of the construct of cultural safety and its applicability to the Australian health care context, Journal of Transcultural Nursing 18: 247–256. Jones C (2000) Levels of racism: A theoretic framework and a gardener’s tale, American Journal of Public Health 90: 1212–1215. Karlsen S and Nazroo J (2002) Relation between racial discrimination, social class and health among ethnic minority groups, American Journal of Public Health 92: 624–631. King (2000) The New Zealand Health Strategy, Ministry of Health,Wellington, New Zealand. Kirchheimer S (2003) Racism should be a public health issue, British Medical Journal 326: 65–66. Leininger M (1978) Transcultural nursing: Concepts, theories and practices, John Wiley, New York. Leininger MM (1985) Transcultural care diversity and universality: A theory of nursing, Nursing and Health Care 6: 209–212. Leininger MM (1988) Leininger’s theory of nursing: Cultural care diversity and universality, Nursing Science Quarterly 1: 152–160. Leininger MM (1996) Culture care theory, research and practice, Nursing Science Quarterly 9(2): 71–78. Leininger MM (2001) Cultural Care Diversity and Universality:A theory of nursing, National League for Nursing Press, New York. Leininger MM and McFarland MR (2006) Culture Care Diversity and Universality: A worldwide nursing theory, 2nd edn, Jones & Bartlett, Sudbury, MA. McCloskey B and Diers D (2005) Effects of New Zealand’s health reengineering on nursing and patient outcomes, Medical Care 43: 1140–1146.
Volume 28, Issue 1–2, April 2008
CN
187
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 188
Denise Wilson
McEldowney R, McDonald S, Richardson F,Turia D, Laracy K and Scott W (2006) Opening Our Eyes – Shifting our Thinking,Victory University of Wellington,Wellington, New Zealand. McKenzie K (2003) Racism and health: Antiracism is an important health issue, British Medical Journal 326: 65–55. Ministry of Health (2006) Tatau Kahukura: Ma- ori Health Chart Book, Public Health Intelligence Monitoring Report No. 5, Ministry of Health, Wellington, New Zealand. Mizrachi N, Shuval JT and Gross S (2005) Boundary at work: Alternative medicine in biomedical settings, Sociology of Health & Illness 27:20–43. Moir M (1994) Mataahua Wa-hine: Images of Ma-ori Women.Tandem Press, Auckland, New Zealand. Morse JM (1991) Strategies for sampling, in JM Morse (ed), Qualitative Nursing Research: A Contemporary Dialogue, pp 1127–1145, Sage Publications, Newbury Park CA. Nursing Council of NZ (2005) Guidelines for Cultural Safety, the Treaty of Waitangi, and Ma-ori Health in Nursing Education and Practice, Nursing Council of NZ,Wellington, New Zealand. Nursing Council of NZ (2008) Continuing Competence Framework, accessed at http://www .nursingcouncil.org.nz/contcomp.html on 28 March 2008. Papps E (2002) Cultural safety:What is the question, in E Papps (Ed), Nursing in New Zealand: Critical Issues Different Perspectives, pp 95–107, Pearson Education, Auckland, New Zealand. Polaschek NR (1998) Cultural safety: A new concept in nursing people of different ethnicities, Journal of Advanced Nursing 27: 427–457. Polit DF and Hungler BP (1991) Nursing Research: Principles and Methods, 4th edn, J.B. Lippincott, Philadelphia PA. Public Health Group (1997) Whaia Te Whanaukataka: Oraka Whanau – The Wellbeing Of Maori Whanau:A Discussion Document, Ministry of Health,Wellington, New Zealand. Ramsden I (1990) KawaWhakaruruhau: Cultural Safety in Nursing Education, Ministry of Health, Wellington, New Zealand. Ramsden I (1992) Teaching cultural safety, NZ Nursing Journal, June: 21–28. Ramsden IM (2002) Cultural Safety and Nursing 188
CN
Volume 28, Issue 1–2, April 2008
Education in Aotearoa and Te Pounamu. Unpublished Doctoral Thesis.Victoria University of Wellington, New Zealand, accessed at http://culturalsafety.massey.ac.nz/ on 6 August 2007. Reid P and Robson B (2006) The state of Ma-ori health, in M Mulholland (ed), State of the Ma-ori Nation:Twenty-First-Century Issues in Aotearoa, pp 17–32, Reed Publishing, Auckland, New Zealand. Reid P, Robson B and Jones CP (2000) Disparities in health: Common myths and uncommon truths, Pacific Health Dialog 7: 38–47. Rosenjack Burchum JL (2002) Cultural competence: An evolutionary perspective, Nursing Forum 37: 5–15. Samson C (1999) Biomedicine and the body, in C Samson (Ed), Health Studies, pp 3–21, Blackwell, Oxford. Schreiber RS (2001) The ‘how to’ of grounded theory: Avoiding the pitfalls, in RS Schreiber and PN Stern (eds), Using Grounded Theory in Nursing, pp 55–58, Springer, New York. Sibthorpe B, Anderson I and Cunningham J (2001) Self-assessed health among Indigenous Australians: How valid is a global question? American Journal of Public Health 91: 1660–1663. Smith LT (1999) Decolonising Methodologies: Research and Indigenous Peoples, University of Otago Press, Dunedin, New Zealand. Sporle A (2003) ‘So Ma-ori fits in how?’ – The realities of attempting to implement kaupapa Ma-ori practice evaluation in a contractual situation, in N Lunt, C Davidson and K McKegg (Eds), Evaluating Policy And Practice:A New Zealand Reader, pp 64–67, Pearson Education New Zealand, Auckland, New Zealand. Wepa D (2003) An exploration of the experiences of cultural safety educators in New Zealand: An action research approach, Journal of Transcultural Nursing 14: 339–348. Wepa D (2005) Cultural Safety in Aotearoa New Zealand, Pearson Education, Auckland NZ. Wilson DL (2004) Nga- kairaranga oranga – The weavers of health and well-being: A grounded theory study. Unpublished PhD Thesis, Massey University, New Zealand.
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 189
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 189–197.
Nursing care of vulnerable populations using a framework of cultural competence, social justice and human rights ABSTRACT
Key Words human rights; ethics; social justice; cultural competence; nursing care of vulnerable populations/ refugees/asylum seekers
The article attempts to present a model linking cultural competence with advocacy for social justice and protection of human rights in caring for vulnerable groups such as refugees and asylum seekers. Using the human rights principle focuses the moral obligation to address social inequities and suffering of vulnerable populations. Cultural competent care and culturally-congruent actions place the universal principles of social justice and protection of human rights within the cultural contexts of people’s lives and the environment in which they are situated. Compassion is identified as the key component for culturally-competent advocacy for social justice and human rights protection. Compassion compels actions advocating social justice and protection of human rights for marginalised and powerless groups. Educational strategies for developing compassion are centered on collaboration, partnership and advocacy. Integration of experiential and didactic learning relevant to cultural competent care for refugees and asylum seekers are recommended. Received 29 July 2007
Accepted 25 March 2008
CN
DULA F PACQUIAO Associate Professor and Director Center for Multicultural Education, Research University of Medicine and Dentistry of New Jersey Newark NJ, USA, and Practice Coordinator PhD in Urban Health Systems School of Nursing University of Medicine and Dentistry of New Jersey Newark NJ, USA
G
lobalisation has intensified worldwide relations and interdependence resulting from complex economic and social ties that link countries and people around the world (Giddens 2001). A major component of globalisation is migration of great numbers of people from one
region to another across the globe.The twentieth and twenty-first centuries are termed the Age of Diasporas (Helman 2007) as all countries have large numbers of their citizens living in other countries. Migration may be voluntary or involuntary. Involuntary migrants include
Volume 28, Issue 1–2, April 2008
CN
189
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 190
Dula F Pacquiao
refugees, asylum seekers, internally displaced persons, returnees, and stateless persons.These groups have fled their homes because of wars, political upheavals, economic disasters or natural disasters. As a result of their marginal existence and experience with oppression, violence, deprivation or loss, they have multiple physical, psychological, and sociocultural vulnerabilities.This article specifically addresses refugees and asylum seekers as one group of vulnerable populations. Vulnerable population groups are those who are not only particularly sensitive to risk factors but also possess multiple cumulative risk factors.They are more likely than others to develop health problems as a result of exposure to risk or have worse outcomes from these health problems than the rest of the population (Aday 2001). An influx of refugees and asylum seekers necessitates allocation of resources that may tax or overwhelm the receiving country. Competing with other groups for these resources, refugees and asylees may face discrimination, isolation and deprivation. Migration is not limited to movement of people, it also involves movement of ideologies and life ways that may be in conflict with those of the receiving society. Migration for these groups can mean prolonged displacement and traumatic experiences that perpetuate a state of liminality. Vulnerable migrants’ experience with healthcare services and professionals can significantly influence their transition to the new society. Healthcare needs are at the forefront of their multiple and complex needs that bring them in early and direct contact with professionals from the host society and different countries. Although the explicit purpose is humanitarian, this contact can be riddled with cultural conflicts between the migrant and the healthcare providers.
in a neighboring country to escape persecution in their homeland.The United States, Australia and Canada were the top countries hosting refugees. In early 2006, there were about 773 500 asylum seekers or people who fled their country and seek sanctuary in another country by applying for asylum which grants the right to be recognised as bona fide refugees, receive legal protection and material assistance. About 7.1 million internally displaced person (IDPs) exist worldwide. These persons are in similar situations as refugees, but remain in their own countries rather than cross international borders. There are roughly 2.3 million stateless persons worldwide and 1.1 million returnees who return home as soon as circumstances permit but continue to need protection and assistance (UNHCR 2006).
GLOBAL ETHIC OF CARE
Globalisation has heightened the need for health professionals to have a world wide perspective and assume an ethical-moral obligation to enter and function in a worldwide community (Leininger 2002). In her book, Cultivating Humanity, Nussbaum (1997) has proposed the need to have world citizenship skills. One of these skills is the ability to critically evaluate one’s self and one’s own cultural traditions. Critical self-reflection examines one’s own beliefs and practices to determine reasonable support for personal beliefs rather than accept them as absolute truths. Another skill is the ability to see the equality of humanity in order to develop a genuine concern and commitment to the welfare of all persons. Lastly, one needs to have the ability to see the world from the point of view of the other. Understanding and feeling the distress of another provides the impetus for the desire to help. The concept of world citizenship is embodied in the literature on cultural competence. CulMAGNITUDE OF THE PROBLEM In 2005, the UN High Commissioner for Refu- tural competence implies having the capacity gees (UNHCR) estimated approximately 8.4 to function effectively as an individual and an million refugees worldwide who sought safety organisation within the context of the cultural 190
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 191
Nursing care of vulnerable populations beliefs, behaviors, and needs presented by individuals [consumers] and [their] communities (Cross et al 1989). Self-awareness and selfreflection are essential to cultural competence development (Campinha-Bacote 2007). Cultural humility is openness to actively engage in meaningful interactions with others to learn from them by assuming the stance of a learner rather than expert (Tervalon and Murray-Garcia 1998). Appreciation of the equality in cultures is embedded in the need to switch one’s frame of understanding to see the validity of other’s ways of being and take actions that respect and accommodate cultural differences (Pacquiao 2008). Understanding the deepest layer or emic perspective of the other ensures culturally-congruent, supportive and meaningful care (Leininger 2006). Cultural competence has a moral agenda that advances patient/group autonomy and justice. In the US, cultural competent care is identified as the pathway to remove barriers to access to health care and eliminate health disparities. Cultural competence is predicated on a profound understanding of culture and its significant influence in people’s lives. Such understanding promotes respect for cultural differences. Cultural competent caregivers function to minimise the negative consequences of cultural differences (Paasche-Orlow 2004).
GLOBAL ETHIC VERSUS ETHICAL PLURALISM Ethical fundamentalism views ethical principles as universally applicable. Moral truths are viewed as timeless and rooted in human nature independent of societal conventions. By contrast, multiculturalism holds that ethical principles are culturally bound and context dependent (Crigger et al 2001; Harper 2006). Leininger (2006) has advocated for the primacy of examining both similarities and differences across cultures as fundamental to culturally-congruent care. Caring according to Leininger is culturally constituted that needs to be explicated from the
CN
people in order to be meaningful and supportive. Moral assumptions are culture-bound and a society’s moral philosophy is embedded in its healthcare system and actions of health care professionals are often congruent with these premises. Health care in a particular society reflects the dominant cultural norms that transcend professional behaviors and health services (Pacquiao 2008). Culturally competent advocacy is rooted in the commitment to preserve and protect fundamental human rights. A human rights framework compels a healthcare provider to act to facilitate access to services that promote the refugees’ survival, decrease their suffering, prevent injury and death, and promote their security as well as those of their loved ones. Advocacy for social justice is inherent in cultural competent care for vulnerable groups. Social justice implies a shift of emphasis from beneficent and compassionate act to moral obligation.
COMPASSION AND CARING FOR VULNERABLE POPULATIONS The challenge is how to move healthcare professionals to culturally competent advocacy for social justice and human rights protection for populations who are powerless and dependent on others to address their complex vulnerabilities. The key antecedent to action is the development of compassionate health care professionals who can transform others, organisations and communities towards cultural competence. Campinha-Bacote (2007) has posited cultural desire as the central motivation towards ongoing cultural competence development to gain critical knowledge of one’s self and others, acquire cultural skills in dealing with cultural differences and actively engage with diverse groups to promote care effectiveness. Compassion has been identified by several authors (Nussbaum 1997; Crigger, Brannigan & Baird 2006) as the motivation that compels one to act on behalf of others. Compassion is the desire to help which is intimately linked with an
Volume 28, Issue 1–2, April 2008
CN
191
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 192
Dula F Pacquiao
empathetic understanding of the suffering or distress of others. Compassion emerges from the empathetic identity with the suffering of others and a consequent commitment to act in order to relieve such suffering. Empathetic identity is the understanding that one has more similarities rather than differences with others and is interdependent with others. Belief in the collective identity and interdependence of humanity promotes empathy and compassionate actions (Noddings 1984; Nussbaum 1997). Crigger et al (2006) have emphasised compassion as fundamental to a global ethic of care. The belief that human groups are essentially interdependent and are entitled to the same fundamental human rights creates the basis for advocacy for these rights not only for one’s self but also for others. If the caregiver believes in the premise that all persons have the right to access basic health care and be treated with respect and dignity, his/her behavior will more likely be congruent with this belief.
FIGURE 1: CULTURAL
192
CN
CULTURALLY COMPETENT CARE FOR VULNERABLE POPULATIONS A schematic diagram of cultural competent care for vulnerable groups is presented in Figure 1. It attempts to demonstrate the universal core ethical principles of advocacy for social justice and protection of human rights. Social justice is doing what is best for a person or group based on their needs and the fundamental principle that human beings have inalienable rights. Social justice implies that because of certain conditions that increase risks to a person or group compromising their capacity to self-advocate and access to life with quality, actions of health care professionals should be non-malevolence (doing no harm), and ultimately beneficent to them. Cultural competence on the other hand mandates that actions are culturally appropriate within the valued premises of people’s lives and the changes in their social and cultural environment. Hence, advocacy for social justice and human rights protection must be informed by the cultural
COMPETENT CARE FOR VULNERABLE GROUPS
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 193
Nursing care of vulnerable populations context of the people and their situated environment. Although the principle of social justice and human rights are universal, these concepts evolve from human conditions in specific contexts. Hence, there is need to apply these concepts in a culturally competent fashion. Social justice is central to advocating for elimination of health disparities by ensuring the basic human right to access to quality health care. Social justice and human rights principles are necessary conditions for each other thus, fundamentally complementary. Cultural competent care for vulnerable populations is achieved by commitment to both principles. The universal impetus for individuals and groups to move towards advocacy for social justice and human rights protection is compassion. Compassion is the critical motivation that compels people to act on behalf of others which emerges from an affective and cognitive understanding and identification with others’ experiences. It is the fire that ignites the energy to take on actions on problems involving enormous risks, complexities and resources. Compassion requires the ability to distinguish the oppressed from the oppressor, victims from perpetuators, and the disadvantaged from the powerful. Compassion is the commitment to go beyond the purview of one’s own perspectives and affiliations. It is beyond cultural desire (Campinha-Bacote 2007) as it moves the person to action. Compassionate actions need to be culturally congruent and competent otherwise advocating social justice for one group may bring consequent disenfranchisement of others. Culturally competent compassion is immersed in balancing the rights of the vulnerable with those of others. Culturally competent action modes according to Leininger (2006) are embedded in cultural preservation, accommodation and repatterning. One or all there modes of action may be used simultaneously or in a continuum of actions. Cultural preservation maintains the core values, beliefs and practices significant to
CN
the individual or group. Cultural accommodation negotiates with existing cultural differences in order to find a meaningful existence of one’s cultural life ways with those of others. Cultural repatterning attempts to help individuals and groups change their way of life to achieve a healthy, safe and meaningful existence.
CASE EXAMPLES Helsel and Mochel (2002) identified the need by Hmong refugees to take home their placenta because of their belief that one’s soul may not rest in peace if one is not united with one’s afterbirth in death. The practice may not be preserved without accommodating the public health policy of disease prevention and control. Some hospitals have developed policies after consultation with public health officials and pathologists. In the absence of infectious diseases and public health risk to the community, a patient or family can take the placenta home. Disposing the placenta within public health guidelines while accommodating their practices uses cultural accommodation and repatterning. Refugees from the Muslim countries of East Africa have a common need for shelter, food, protection from violence, and basic health services. In working with these communities one needs to address violence and oppression of females and children which may be perpetuated by members of their own group. Culturally competent approaches need to use the three modes of action to advocate for intra and intergroup rights within the context of the cultural organisation of patriarchy and Islamic traditions. While cultural repatterning of societal expectations of women and children may be a long range goal, there is need for an immediate focus on negotiating the security and protection of these women and children. Health care providers need to work with the established social hierarchy and the women to accomplish this goal. In dealing with refugees from third world countries, the hosting country may have legitimate concerns regarding potential spread of
Volume 28, Issue 1–2, April 2008
CN
193
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 194
Dula F Pacquiao
resistant strains of tuberculosis to the general population. This concern however should be accompanied by an equal concern for uninfected refugees who need immediate protection from the disease. Prompt detection and isolation of infected individuals needs to be done while working with the refugee community to develop an understanding of the need for this action (cultural repatterning). With isolation comes the ethical obligation to provide the right of infected refugees’ to treatment. Collaboration with both governmental and non-governmental agencies as well as private donors can help address the lack of resources for control and treatment of the disease in the refugee community.
FOSTERING DEVELOPMENT OF COMPASSION Research has found key educational strategies in facilitating the transformation of the individual’s compassion to action. The core strategies proposed in the model are centered on collaboration, partnership and advocacy. Collaborative partnership with refugees and asylum seekers is built on mutual understanding and empathy. Listening to the stories of refugees and asylees sensitise caregivers to the subjective and highly personal reconstruction of their experiences. This encounter develops empathy for the person’s suffering and facilitates a full understanding of the person as a human being. The professional gains knowledge of the unique context of the person’s life experiences. Giving a voice to their personal narratives provides affirmation of their suffering and existence. Objectification and reduction of the person (Foucault 1994) are prevented by unfolding the story using the individual’s system of meanings replete with biophysical, psychological, spiritual and sociocultural dimensions. Repeated cultural encounters enhances the health care professionals’ ability in demonstrating attentiveness, genuine concern, presence, warmth and empathy. Clinical encounters with 194
CN
Volume 28, Issue 1–2, April 2008
diversity are found to be significant in developing cultural proficiency and effectiveness (Pacquiao 2007). Similarly, by listening to the unabridged stories of others, the healthcare provider learns important lessons in cultural similarities and differences in specific contexts. Keeping a journal of one’s thoughts, feelings and behaviors during the encounter promotes insight into one’s personal biases and reactions. Reflexivity is promoted by analysing one’s own reactions within the context of the purpose and outcome of the encounter. Use of video presentations, case studies or ethnographies of experiences of refugees and asylees can increase’ sensitivity and empathetic understanding of their plight. Fadiman’s (1999) powerful story of the experience of a Hmong refugee family in California is an example of such stories. Fadiman’s book provides insight on how good intentions of healthcare providers created undue suffering on the family because of cultural inappropriateness of their assumptions. It is apropos for learning differential outcomes of caring decisions based on different contexts used by participants. Rigoberta Menchu’s (Burgos-Debray 1994) autobiography is a gripping portrayal of a group of people’s continuing struggle with oppression and violence. It documents the ripple effects of discrimination on the lives of generations of Quiche Indians in Guatemala. These two ethnographies give scenarios of microsocial (Hmong family) and macrosocial (Quiche Indian people) contexts and consequences of professional and organizational cultural imposition and social oppression. Developing collaborative partnerships with refugees and migrant communities promote contextual understanding of their needs.This in turn promotes effectiveness and responsiveness of health services. Omeri, Lennings and Raymond (2006) found that among Afghan refugees in Australia, health care providers’ lack of knowledge of gender and family roles, Islamic religion, language, and health beliefs and practices of the group resulted in stereotypes, in-
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 195
Nursing care of vulnerable populations appropriate care and mistrust.The authors recommended the significant value of collaborating with the refugee community in structuring health care delivery that is responsive to their needs.This process enables the refugees to gain more control of their lives. Healthcare providers need experience in caring for vulnerable populations locally or abroad. Experience with organisations and advocacy groups serving refugees and asylees may include local churches, the Red Cross, homeless shelters, Doctors without Borders, the United Nations and others. Awareness of resources locally, nationally and globally promote access to and development of more comprehensive services. Building collaborative partnerships with organisations and communities is important as refugees and asylees have complex, multiple needs that are both simultaneous and evolving. Partnerships allow sharing of resources, services and best practices across local, national and global contexts. Service learning is an excellent opportunity for nursing students to learn about organisations and the communities they serve. Strengthening the community health nursing component in the curriculum sensitises students to public health issues, social inequities affecting health and community resources. Cultural competence development requires experiential learning over a sustained period. Integration of concepts and learning experiences throughout the curriculum promotes continuity and progression of students’ learning. Progression in clinical learning should be guided by the correlation between the students’ previous and concurrent learning. Curricular integration gives students the opportunity to refine their skills and see progress in caring for people with multiple vulnerabilities which can otherwise be traumatic and overwhelming.
CN
asylum seekers, refugees and resettled migrants. They need to critically evaluate state, national and global policies affecting these populations. They also need the skill to examine practices of other health practitioners for vulnerable populations (Koehn 2006). Knowledge of population-based health risks of refugees and asylum seekers pre and post migration can facilitate early diagnosis, treatment and surveillance. Use of specialty services and access to relevant educational health programs specific to the problems can be facilitated (Carlsten 2003; Cook et al 2006). Health professionals need to have the ability to elicit the complex problems of refugees and migrants. In addition to physical examination, the immigration history, mental illness, anxiety and depression should be assessed. Understanding the cultural support systems within their cultures is important in facilitating a network of support for the refugee. Cultural healers can be of assistance in assisting the refugee in accessing health care in a culturally acceptable and meaningful way (Carlsten 2003). Health professionals need training in working with non-English speakers and using interpreters effectively. Proficiency in the dominant language of the host country is not a requirement for humanitarian entrants (Lamb and Smith 2002) hence, language barriers often result in miscommunication, misdiagnosis and lack of appropriate follow-up (Moreno et al 2001). Selecting interpreters appropriate to the refugee’s dialect, gender and age preferences is based on adequate knowledge of the refugee’s indigenous culture. Bicultural navigators or brokers are recommended to promote use of health services and trust between providers and refugees.
CONCLUSION
Cultural competence is the bridge between ethical fundamentalism and pluralism as it requires adapting initiatives within the life context of IMPLICATIONS FOR EDUCATION Education of health professionals must include the refugees and the new environment where culturally competent care for transnationals, they are situated. Cultural competent care for
Volume 28, Issue 1–2, April 2008
CN
195
CNJ 28_1_2_internal.qxd
CN
30/07/2008
9:49 PM
Page 196
Dula F Pacquiao
refugees and asylum seekers who have multiple and complex needs and rendered powerless by their marginalised status and prolonged experience with vulnerabilities requires commitment to social justice and human rights protection. Leininger’s culturally congruent action modes of cultural preservation, accommodation and repatterning are applicable in advocating for refugees and asylum seekers. Ideals of advocacy for social justice, human rights protection and cultural competent care remain abstract ideologies without the collective identification with the suffering and distress of others. Compassion is the necessary spark that prompts action and enactment of these ideologies. Compassion is rooted in the belief that cultural competent advocacy for social justice and protection of human rights is a moral obligation, not merely an act of good will and non-malevolence. It enables achievement of beneficent outcomes for individuals and groups by minimising the negative consequences of vulnerabilities and cultural differences. With globalisation, health care professionals need to have world citizenship skills by developing a profound understanding of their own life ways and those of others. Health professionals need to develop a sense of collective identity with others which brings a consequent appreciation of the influence of culture in all aspects of life, and respect for cultural differences and human rights across humanity.This compassionate understanding and identity with others is the key ingredient for taking action to reduce social inequities resulting in unfair burden of illness and disparate access to quality health services in vulnerable groups.
References Aday L (2001) At Risk in America: The health and health care needs of vulnerable populations in the United States, 2nd edn, Jossey-Bass: San Francisco. Burgos-Debray E (ed) (1994) I, Rigobertya Menchu an Indian woman in Guatemala,Verso: USA. Campinha-Bacote J (2007) The Process of Cultural Competence in the Delivery of Healthcare Services, 5th ed, Ohio, Transcultural CARE Associates Press, http://www.
196
CN
Volume 28, Issue 1–2, April 2008
transculturalcare.net/Resources.htm. Accessed July 22 2007. Carlsten C (2003) Refugee and immigrant health care, Ethnomed http:www.ethnomed.org. Accessed July 29 2007. Crigger NJ, Holcomb L and Weiss J (2001) Fundamentalism, multiculturalism and problems of conducting research with populations in developing nations, Nursing Ethics 8: 459–468. Crigger NJ, Brannigan M and Baird M (2006) Compassionate nursing professionals as good citizens of the world, Advances in Nursing Science 29: 15–26. Cook PA, Downing J, Rimmer P, Syed Q and Bellis MA (2006) Treatment and care of HIV positive asylum seekers, Journal of Epidemiology and Community Health 60: 836–838. Cross T, Bazron B Dennis K and Isaacs M (1989) Towards a Culturally Competent System of Care,Volume I. Georgetown University Child Development Center, CASSP Technical Assistance Center:Washington DC. Fadiman A (1999) The Spirit CatchesYou andYou Fall Down. Farrar Strauss and Giroux, NY. Foucault M (1994) The Birth of the Clinic:An archeology of medical perception.Vintage Books, NY. Giddens A (2001) Sociology. Polity: Cambridge. Harper MG (2006) Ethical multiculturalism an evolutionary analysis, Advances in Nursing Science 29: 110–124. Helman C (2007) Culture, Health and Illness, 5th edn, Oxford University Press: NY. Helsel DG and Moche M (2002) Afterbirths in the afterlife: Cultural meaning of placental disposal in a Hmong American community, Journal of Transcultural Nursing 13: 282–286. Koehn PH (2006) Transnational migration, state policy and local clinician treatment of Asylum seekers and resettled migrants, Global Social Policy 6: 21–26. Lamb CF and Smith M (2002). Problems refugees face when accessing health services, NSW Public Health Bulletin 13: 161–163. Leininger M (2002) Transcultural nursing and globalisation of healthcare: Importance, focus and historical aspects. In Leininger M and McFarland M, Transcultural Nursing Concepts,Theories, Research and Practice, 3rd edn, pp 3–44, McGraw Hill: New York. Leininger M (2006) Culture Care Diversity and Universality a Worldwide Nursing Theory, 2nd edn, Jones & Bartlett: Massachussetts. Moreno A, Piwowarczyk L and Grodin MA (2001). Human rights violations and refugee health, Journal of the American Medical Association 285: 1215. Nodding N (1984) Caring, University of California Press: Berkeley. Nussbaum M (1997) Cultivating Humanity, Harvard University Press: London. Omeri A, Lennings C and Raymond L (2006) Beyond asylum implications for nursing and health care delivery for Afghan refugees in Australia, Journal of Transcultural Nursing 17: 30–39.
CNJ 28_1_2_internal.qxd
30/07/2008
9:49 PM
Page 197
Nursing care of vulnerable populations Pacquiao DF (2007) The relationship between cultural competence education and increasing diversity in nursing schools and practice settings, Journal of Transcultural Nursing 18: 28S–37S. Pacquiao DF (2008) Culturally-competent ethical decision making. In Andrews M and Boyle J, Transcultural Concepts in Nursing Care, 5th edn, pp 408–423. Lippincott Williams & Wilkins: Philadelphia. Paasche-Orlow M (2004) The ethics of culturalcompetence, Academic Medicine 79: 347–350.
***
CN
Tervalon M and Murray-Garcia J (1998). Cultural humility versus cultural competence: A critical distinction in defining physician-training outcomes in multicultural education, Journal of Health Care for the Poor and Underserved 9: 117–125. United Nations High Commissioner for Refugees (UNHCR) (2006) Refugees by Numbers 2006 edn, http: //www.unhcr.org/basics/BASICS/3b028097c.html, Accessed July 22 2007.
FORTHCOMING
I N N O VAT I V E A P P R O A C H E S
TO
2008
***
F A M I LY V I O L E N C E
Special DOUBLE ISSUE of the Journal of Family Studies (ISSN 1322-9400) ISBN 978-1-921348-05-1
softcover
iv + 172 pages
October 2008
Edited by Margot Schofield and Rae Walker (La Trobe University, Melbourne) • Editorial – Lawrie Moloney • Guest editorial – Margot J Schofield, Rae Walker • Intimate partner violence in Vietnam and among Vietnamese diaspora communities in Western societies: A comprehensive review – Angela J Taft, Rhonda Small, Kim A Hoang • Violence against women in Papua New Guinea – Iona Lewis, Bessie Maruia, Sharon Walker • Changed forever: Friends reflect on the impact of a woman’s death through intimate partner homicide – Patricia McNamara • Silent parental conflict: Parents’ perspective – Magdalena M Kielpikowski, Jan E Pryor • Problems in the system of mandatory reporting of children living with domestic violence – Cathy Humphreys • Indigenous family violence and sexual abuse: Considering pathways forward – Kylie Cripps, Hannah McGlade • Violence allegations in parenting disputes: Reflections on court-based decision making before and after the 2006 Australian family law reforms – Lawrie Moloney • An historical perspective on family violence and child abuse: Comment on Moloney et al, Allegations of Family Violence, 12 June 2007 – Nicholas Bala • Family violence in children’s cases under the Family Law Act 1975 (Cth): Past practice and future challenges – Rae Kaspiew
• The idealized post-separation family in Australian family law: A dangerous paradigm in cases of domestic violence – Amanda Shea Hart, Dale Bagshaw • The rhetoric and reality of preventing family violence at the local governance level in Victoria, Australia – Carolyn Whitzman, Tracy Castelino • The invisibility of gendered power relations in domestic violence policy – Karen Vincent, Joan Eveline • Baby lead the way: Mental health group work for infants, children and mothers affected by family violence – Wendy Bunston • Understanding the impact of abuse and neglect on children and young people: Analysis of referral and assessment data from a therapeutic intervention program – Margarita Frederico, Annette Jackson, Carlina M Black • Intrafamilial adolescent sex offenders: Family functioning and treatment – Jennifer A Thornton, Gillian Stevens, Jan Grant, David Indermaur, Christabel Chamarette, Andrea Halse • A brief counseling intervention by health professionals utilising the ‘readiness to change’ concept for women experiencing intimate partner abuse: The weave project – Kelsey L Hegarty, Lorna J O’Doherty, Jane Gunn, David Pierce, Angela J Taft
Course co-ordinators are invited to contact the Publisher for an adoption evaluation copy. eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
e C ontent
PTY
management LTD
Volume 28, Issue 1–2, April 2008
CN
197
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 198
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 198–206.
Nurses on the move: Diversity and the work environment ABSTRACT Key Words nurse; nursing; migration; equal opportunity; work environment; discrimination; recruitment; ethics
Over 191 million people make up the international migrant population of today.Their numbers have doubled since 1970, with women now accounting for almost half.The migrant population has been transformed and is changing the very nature of society in both source and destination countries. Greater differences in culture, language, work relationships, and coping mechanisms – in short, greater diversity in society and the workplace – offer many opportunities for excellence in transcultural nursing but also provides fertile ground for discrimination, victimisation, harassment and isolation.This article explores and describes current nurse migration flows, the impact migration has on nurses and the value of positive practice environment for the full integration of international nurses. Received 17 July 2007
Accepted 31 March 2008
CN
following scenarios reflects on some of the experiences of migrating nurses with implications for nurse shortages. MIREILLE KINGMA Consultant Nursing and Health Policy International Council of Nurses Geneva, Switzerland
INTRODUCTION
A
ccording to the International Organization for Migration, women migrants have become agents of economic change as they enter the international labour market and participate in a new distribution of global wealth (IOM 2003). This article looks at current nurse migration flows, the impact migration has on nurses and the value of positive practice environments for the full integration of international nurses.The
198
CN
Volume 28, Issue 1–2, April 2008
I feel safe. I am happy here and can now plan my life. Fatima Ansari,*1 born in the Middle East and a member of an ethnic minority, dreamed of being a nurse. Making the wish a reality was a continuing challenge and in spite of the powerful social pressures, Ansari persevered and received her diploma with the promise of a wonderful future. However, victimised daily by the harmful and discriminatory practices of her colleagues and employers, she was offered only sporadic temporary work contracts and earned very little money. Given no hope of a better life in her home country, Ansari finally decided to join her sister and brother in Sweden. Recalling her years in Sweden, Ansari insists they have
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 199
Nurses on the move: Diversity and the work environment been positive. ‘I have been treated well – better than in my home country.The decision to move was mine and I would do it again’ (Kingma 2006: 1). Vicki Bigambo* also faced serious professional and personal problems in her home country of Tanzania. Proposed a job in a Glasgow nursing home, she signed the contract that was to offer her a new life in the United Kingdom. Upon arrival, the recruitment agency took her passport and attempted to force her into signing a new contract for a lower salary, longer hours and a new location far from the city. Bigambo was warned that if she spoke to anyone about her situation she would be deported (Kingma 2006). Fatima Ansari and Vicki Bigambo are part of the growing phenomenon of global mobility. Today, over 191 million people live in countries other than where they were born. This population has doubled since 1970, with women now accounting for almost half, many migrating without their families and alone (IOM 2005; Timur 2000; UN 2006). The migrant population has been transformed and is changing the very nature of society in both source and destination countries.
LITERATURE REVIEW Nursing has always been a mobile profession. Thousands of nurses every year migrate in search of better pay and working conditions, career mobility, professional development, a better quality of life, personal safety, or sometimes just novelty and adventure (Kingma 2006). Already in the 1970s, more Filipino nurses were registered in the United States and Canada than in the Philippines (Martineau, Decker & Bundred 2002). Today, however, a wider range of supplier countries is satisfying the growing labour needs of an increasing number of destination countries, developing as well as industrialised. For example, the number of countries sending international nurse recruits to the United Kingdom is known to have increased from
CN
seventy-one in 1990 to ninety-five in 2001 (Buchan & Sochalski 2004). Factors facilitating the flow between source and destination countries include long-standing trade and economic ties, a history of colonial relationships, the existence of established transnational communities or diaspora (see the case of Fatima Ansari) as well as a shared culture, religion or language. Traditional flows in South–North migration are, however, subject to change over time. For example, the Philippines, once the leading source of nurse migrants to Ireland and the United Kingdom, was outranked by India in 2005 (Kingma 2007). The percentage of foreign-educated physicians working in Australia, Canada, the United Kingdom (UK) and the United States (US) is currently reported to be between 21% and 33%, while foreign-educated nurses represent 5–10% of these countries’ nurse workforce. New Zealand reports that 21% of its nurses are trained abroad, a significant increase in the last decade (WHO 2006). In 2005–2006, registered nurses were the largest group of workers recruited by Australian organisations (ANMC 2007). In Switzerland, 30% of employed registered nurses are foreign-educated and in at least one university hospital 70% of new recruits are from abroad (Artigot 2003). In 2005, 84% of the new entrants to the Irish nursing register were foreign-educated; a total of 60% if European Union source countries are excluded (An Bord Altranais 2005). In 2002, the number of foreign-educated nurse entrants to the UK Nursing and Midwifery Council Register exceeded the number of newly qualified nurses educated in the UK (Ball and Pike 2004).While the percentage of new foreign-educated nurse registrations in the UK has decreased in recent years (approximately 35% in 2004–2005) (NMC 2005), there is a reported bottleneck of 37 000 foreign nurses in the country waiting for clinical placements in order to fulfill accreditation requirements (Parrish & Pickersgill 2005).
Volume 28, Issue 1–2, April 2008
CN
199
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 200
Mireille Kingma
MIGRATION FLOWS
RISKS
Traditionally, the flow of migrant nurses tended to be North–North or South–South. It is the rapid growth in international recruitment from developing countries to industrialised countries that has gained most media and policy attention in recent years (Dugger 2006). The World Health Organization estimates that 30,000 nurses and midwives educated in sub-Saharan Africa are now employed in seven OECD countries2 (WHO 2006). There is evidence that nurses often duplicate the ‘carousel’ movement of physicians – using stops in various destination countries to build up their skills and credentials (Martineau et al 2002). A nurse may move from Ghana to the United Kingdom, then head to Canada only to leave one or two years later for what is often the ultimate destination, the United States. Or the route may be even more circuitous, starting in India with stops in Saudi Arabia, the United Kingdom, and then North America. For example, 40% of the surveyed Filipino nurses employed in the United Kingdom had previously worked in Southeast Asia and the Middle East (Opiniano 2002). Although migration flows have been based on long-standing political, economic, and social ties, new sources feeding the international skill pool are being sought as the nursing shortage is affecting an increasing number of countries. As mentioned, a common language has often been a critical factor in establishing migration flows in the past.Yet, industrialised countries are now considering the 1.2 million Chinese nurses an untapped source of nursing human resources. In spite of language differences, countries like Saudi Arabia, the United States, the United Kingdom, Ireland and Australia, have already recruited Chinese nurses. Greater differences in culture, language, work relationships and coping mechanisms – in short, greater diversity in society and the workplace – offer many opportunities for excellence in transcultural nursing but also provide fertile ground for discrimination, victimisation, harassment and isolation.
Career moves often enable nurses to achieve personal career goals, professional development and improve their quality of life. This in turn promotes job satisfaction and excellence in nursing practice while supporting nurse retention as well as recruitment.The dangers must, however, also be acknowledged. Nurses may be employed under false pretences or misled as to the conditions of work and possible remuneration and benefits. International nurses may be particularly vulnerable as the terms of a work contract are harder to verify when distance and language present significant barriers (ICN 2002).
200
CN
Volume 28, Issue 1–2, April 2008
ABUSE AND EXPLOITATION Abuse may begin with the recruitment process itself. According to the International Council of Nurses, examples include: • Hidden charges (eg agency fee); • Double charges (eg agency and employer recruitment fee); • False/misleading information (eg accommodation, orientation); • Inappropriate accommodation charges; • Non-payment or non-compliance with the terms of the contracted agreement (eg return flight); • Implied but refused access to grievance procedures; • Imposed non-paid orientation period; • Unspecified conditions of work (eg hours, leave, duration of contract, insurance); • Unspecified work assignment (eg contagious ward with no barrier equipment); • Abusive treatment (eg retention of travel documents, forced re-negotiation of contract upon arrival); • Hidden or unclear penalty clauses (eg payment of fine if employment period not respected); • Absent termination clause. (International Council of Nurses 2001: 7–8)
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 201
Nurses on the move: Diversity and the work environment A wide range of abusive practices exists all along the recruitment process. Bogus agencies have charged nurses for services that they will never provide. In the Philippines, Ghana and India, nurses have reported registering with employment agencies only to find when they return for a progress report, that the businesses no longer exist and their money has disappeared. Accommodation charges have also been a vehicle for exploitation.Taking one case in Scotland, four nurses were obliged to live in a twobedroom apartment, each charged an exorbitant price. While the usual rent for a similar apartment was £395, the nurses together were paying £1,100 per month, three times the going rate. Accommodation abuses have also been reported in the United States. To give but one example, eight migrant nurses were allocated a four-bed room in a hospital dormitory. The nurses were then rostered or scheduled to work different shifts so that the beds were in constant use (Kingma 2006). In a letter to the Joint Standing Committee on Migration Department of the House of Representatives, the Australian Nursing Council confirms the existence of exploitation of overseas nurses by recruiters in the country.While the number of such complaints was small, the ANC recognised that migrants are loath to complain in fear of losing their visa (ANC 2003). For further examples of abuse and exploitation, see Omeri (2006). The lack of regard for international nurses’ expertise and past work experience negates their sense of professional worth and undermines their confidence (Omeri & Atkins 2002), making them more vulnerable to exploitation and discrimination, and contributes to the deterioration of a much-needed skill pool. Nurses, who in the past may have run hospitals or provided expert clinical care, may be obliged to do domestic chores in order to keep their work permit, eg putting out rubbish, ironing bed linen, mopping floors or washing the emp-
CN
loyer’s car. One 31-year-old Kenyan nurse now working in the United Kingdom expresses her grief and anguish: ‘Some of the skills I had – they’re dead because I don’t have a chance to use them’ (Allan and Larsen 2003: 6). Deskilling – the loss of skills due to lack of regular practice or active use – constitutes a type of discrimination that is both an emotional and professional insult. In the light of the critical nursing shortage, it is an unacceptable waste of precious resources.
DISCRIMINATION: IMPACT AND OUTCOME Migrant nurses are frequent victims of poorly enforced equal-opportunity policies and pervasive double standards. Colleagues may purposefully pretend to misunderstand them, try to undermine their professional skills, refuse to help, and sometimes even bully them, all of which increases the nurses’ sense of isolation. Alice Winston,* a Jamaican nurse, remembers the prevalent racism in her US hospital perpetrated not only by native-born nurses but by other migrant groups: There was bias in the assignments and rostering. Colleagues would set me up to make mistakes.They would leave out vital information in the reports between shifts. The Filipino nurses would talk together in their language. They created a clique – I felt marginalised, an outcast.The other nurses intimidated me. Racism is scary.You get attacked because of your ethnic origins. (Kingma 2006: 70–71) The terrible psychological impact of such treatment is obvious. The threat to patient safety is of serious concern. Recent Australian research documents the discrimination practised against foreign-educated nurses. The complexity of the phenomenon is highlighted, as different groups of migrant nurses are reserved special treatment. Race,
Volume 28, Issue 1–2, April 2008
CN
201
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 202
Mireille Kingma
gender and religion are not the only basis for discrimination. The various national groups were found to be treated differently on the basis of their language background (Hawthorne 2001). Analysing the career paths of Englishspeaking background (ESB) and non-Englishspeaking background (NESB) migrant nurses, Hawthorne (2001) concluded that discrimination is indisputable.While both groups of nurses found employment after registration, significant and persistent labour market segmentation was evident over time. NESB nurses proved to be much less likely to be promoted despite their qualifications and relative seniority. A disproportionate concentration of foreign nurses with non-English-speaking backgrounds was deployed in the ‘least prestigious’ nursing home sector – a sector in the process of redefinition as ‘foreign labour’ (Hawthorne 2001: 226).The reality of such high proportions of migrant professionals in this sector has dramatically modified its image (Kingma 2006). These jobs may become doubly stigmatised – first because they are too difficult, too remote, or too low tech, and then again because it is work only foreigners will do. Employers, supervisors, and colleagues are not the only ones who discriminate against migrant nurses. The Royal College of Nursing (UK) declared that two-thirds of black and ethnic minority nurses report having been racially harassed by patients. In some cases, patients have refused the care given by nurses from certain ethnic groups or nationalities (Ball & Pike 2004). For decades, the pay and benefits of foreign nurses contracted to work in the Middle East depended on where they had been educated. Although employed as professional nurses under the same working conditions and often with the same responsibilities, those coming from the more industrialised counties, like the United States, the United Kingdom, and Australia, were paid higher salaries than those emigrating from the Philippines, China, or India. This practice 202
CN
Volume 28, Issue 1–2, April 2008
goes for the most part unchallenged by the nurses from developing countries, who accept the lower pay as a condition of employment (Kingma 2006). Paradoxically, with the aggressive recruitment of international nurses and multiple employment incentives, many domestic-educated nurses feel their employers are exercising reverse discrimination against loyal staff.They see sign-on bonuses, housing and travel subsidies, educational grants, and promises of good schedules being given to international recruits while they are neglected. Recruitment incentives have tended to be more easily introduced than retention measures. National nurses may sometimes perceive the support given to international nurses as preferential treatment and a form of discrimination against them (Payne 2003). Discrimination, in any shape or form, is highly destructive. It undermines the person but also society and its health system as a whole (Adams & Kennedy 2006). De-skilling, discrimination and marginalisation of the international nurse threatens patient safety and disrupts the health team cooperation dynamic required to advance the delivery of care.
RECOGNISING STRENGTHS: VALUING DIVERSITY The examples previously discussed illustrate various forms of discrimination, exploitation and abuse present in the recruitment process itself – before the international nurse physically enters the workplace. Increasingly, there have been calls for an ethical framework for nurse recruitment.The International Council of Nurses (ICN) in its Position Statement on Ethical Nurse Recruitment ‘denounces unethical recruitment practices that exploit nurses or mislead them into accepting job responsibilities and working conditions that are incompatible with their qualifications, skills and experience. ICN and its member national nurses’ associations call for a regulated recruitment process based on ethical principles that guide informed decision-
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 203
Nurses on the move: Diversity and the work environment making and reinforce sound employment policies on the part of governments, employers and nurses’ (2007a: 1).These key principles include: • Effective human resources planning, management and development, leading to national self-sustainability; • Credible nursing regulation; • Access to full employment; • Freedom of movement; • Freedom from discrimination; • Good faith contracting; • Equal pay for work of equal value; • Access to grievance procedures; • Safe work environment; • Effective orientation/mentoring/supervision; • Employment trial periods; • Freedom of association; • Regulation of recruitment. The principles above, while particularly important for vulnerable migrant populations, should also be applied to the recruitment of domestically-educated nurses. They provide a framework that supports excellence in the delivery of services, effective human resources management and high productivity of health systems. The Australian Nursing and Midwifery Council in its Position Statement on the Ethical Recruitment of Internationally Qualified and Registered Nurses and Midwives supports the principles and practice of ethical recruitment, consistent with the ICN and International Confederation of Midwives positions (see www.an mc.org.au).
CRITICAL QUESTIONS The potential perils of exploitation and abuse exist when making career moves that involve changing countries as well as workplaces. Too often, this may result in a decreased income, lower professional status and/or threatened personal safety. Well-informed decisions are part of the solution. Access to information needs to be ensured and facilitated by nurses’ professional and trade union organisations.
CN
Career moves must be decided on the grounds of reliable information on the key stakeholders involved, the contract process, conditions of employment, benefits, imposed fees and the impact on nurses’ present and future quality of life. The basic questions that need to be posed before making an international career move are: • What are the credentials of the recruitment/employment agency? • What are the credentials of the employer? • What are the conditions of employment? • What is the job description? • What is the impact of this career move? (ICN 2002: 16) Similar precautionary evidence-gathering is recommended by the Australian Nursing Federation in their policy statement on Nurses Working Overseas (see www.anf.org.au). Once these questions have been answered to satisfaction and the decision to accept employment abroad has been taken, workplace strategies must be in place to make the most of international nurses’ skills and their potential for professional growth. For further useful information, see Omeri (2006).
POSITIVE PRACTICE ENVIRONMENTS The beneficial effects of positive practice environments on health service delivery, health worker performance, patient outcomes and innovation are well documented (ICN 2007b). A workplace that promotes workers’ safety, provides opportunities for life-long learning, encourages professional advancement and supports employees’ participation in decision-making tends to have a highly motivated, committed and productive staff, as demonstrated by the accredited Magnet hospitals (Aiken et al 2002). These factors translate into lower burnout rates, higher job satisfaction and better patient outcomes. According to TS Kristensen (1999), the following factors are required for optimal social and psychological well-being in the workplace:
Volume 28, Issue 1–2, April 2008
CN
203
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 204
Mireille Kingma
• Demands that fit the resources of the person (absence of work pressures); • A high level of predictability (job security and workplace safety); • Good social support from colleagues and managers and access to education and professional development opportunities (team work, study leave); • Meaningful work (professional identity); • A high level of influence (autonomy, control over scheduling, leadership); and • A balance between effort and reward (remuneration, recognition, rewards). (Kristensen 1999 cited in ICN 2007b). The link between the above factors (or rather their absence) and the cases of international nurse exploitation described previously is easily drawn. It comes as no surprise that the full utilisation of the knowledge and skills of international nurses will depend to a large extent on their integration into the health care team.This in turn will depend on the quality of the practice environment. Treating people fairly, with respect and dignity, is the foundation and guiding principle of positive practice environments. Environment issues need to be addressed if the working conditions and work performance of the international nurse are to be improved. There are many positive practice initiatives developed for the integration of international nurses globally (Adams & Kennedy 2006, see case studies at http://www.intlnursemigration .org/uk-event.shtml).They are often guided or influenced by equality legislation, mutual agreements, ethical recruitment practices, educational standards and the proactive work of numerous national nurses associations. Employers are developing good human resources management practices with comprehensive orientation programmes, language preparation, mentoring, education support and career progression. The value of such an approach is recognised by professional regulatory bodies, including the Australian Nursing and Midwifery 204
CN
Volume 28, Issue 1–2, April 2008
Council (ANMC 2007), as well as professional unions such as the Australian Nursing Federation (see their policy on Recruitment of Nurses from Overseas www.anf.org.au). Cultural awareness programmes, both for the ‘home nurses’ and the international nurses, are increasingly being developed and implemented, making a difference for nurses, their patients and families.
WHERE DO WE GO FROM HERE? In order to support long-term integration and retention of international nurses, it is necessary to have credible and strong human resource management systems that are capable of adapting to multiple and changing contexts. Traditionally, human health resources management has ranked low on the policy agenda. This has most certainly contributed to the historically high turnover rates in nursing, that destabilise the health work environment and seriously threaten health systems’ ability to care effectively for patients, ie loss of continuity of care, increased workloads and staff stress levels, disrupted communication channels, reduced efficiency and higher costs (WHO 2006). Human resource practices that support adequate staffing, investment in education, teamwork, employee autonomy and empowerment are associated with high levels of retention and enhanced organisational outcomes and performance (The European Observatory on Health Systems and Policies 2006, cited in Adams & Kennedy 2006). A multi-prong approach is required to effectively recruit and retain international nurses. The process must screen and inform international recruits prior to employment, prepare existing staff before the arrival of the international nurse and, finally, provide on-going support through fair human resource management practices. Prior to developing an integration strategy at the organisational level, each employer, in consultation with nurse representatives, should identify the key issues and challenges facing
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 205
Nurses on the move: Diversity and the work environment international nurses in their organisation (Adams & Kennedy 2006). This will require a good communication system, a clear understanding of the issues to be addressed, a transparent problem-solving approach and effective grievance procedures. Evidence suggests there are four major areas to be addressed when attempting to retain and educate international nurses once employed in their new destination countries: • Socialisation to the professional nursing role; • Acquisition of language and other communication skills; • Development of workplace competence, both clinical and organisation; • Availability of support systems and resources within the organisation. (Ryan 2003 cited in Adams & Kennedy 2006)
CN
care workplaces are critical if quality patient care is to be ensured.The delivery of safe, effective and efficient health services depends on the competence of health workers and a work environment that supports performance excellence. The on-going underinvestment in the health sector in many countries has resulted in a deterioration of working conditions. This has had a serious negative impact on the recruitment and retention of health personnel, the productivity and performance of health facilities, and ultimately on patient outcomes (ICN 2006;WHO 2006). ICN has launched a global call to address and improve the serious deficiencies currently existing in the health work environment in all regions.‘We believe patients and the public have the right to the highest performance from nurses and other health care professionals. This can only be achieved in a workplace that enables and sustains a motivated, well-prepared workforce,’ declared Hiroko Minami, ICN President (ICN 2007c). In the light of the multi-cultural and multi-national workforce that presently exists in many health systems of the world, the full integration of international nurses is a mandatory step in meeting national and international health targets.The fair treatment of international nurses remains the key to respecting universally accepted human and workers’ rights.
Building positive practice environments will assist the integration of international nurses, support nurses in the host environments and contribute to creating a dynamic team by valuing and using the skills and abilities of all nurses. The enriched cultural backgrounds international nurses bring to the workplace should facilitate the exchange of information with regard to a wide range of health beliefs and cultural practices. A more comprehensive understanding in this area will facilitate the development of culturally competent care practices that are Endnotes required of all nurses.These interventions must 1 An asterisk following a name indicates a be integrated in curricula at the basic and postpseudonym. basic levels if services to a diverse patient popu- 2 Canada, Denmark, Finland, Ireland, Portulation are to be effective. At the same time, gal, United Kingdom, United States international nurses will need to develop a cultural understanding of the new country, its References health care environment, practice settings and Adams E and Kennedy A (2006) Positive Practice Environments: Key Considerations for the Development clinical expectations (ANMC 2007). This can of a Framework to Support the Integration of most easily be done through targeted and wellInternational Nurses, International Council of supported orientation programmes. Nurses, Geneva.
IMPROVING QUALITY PATIENT CARE The evidence demonstrates that quality health
Aiken L, Clarke S, Sloane D, Sochalski J and Silber J (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction, Journal of the American Medical Association 288: 1987–1993.
Volume 28, Issue 1–2, April 2008
CN
205
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 206
Mireille Kingma
Allan H and Larsen J (2003) We Need Respect: Experiences of Internationally Recruited Nurses in the UK, Royal College of Nursing, London. An Bord Altranis (2005) Registration Information 2005. Accessed at http://www.nursingboard .ie on July 10, 2006. Artigot F (2003) Les hôpitaux canadiens battent le rappel des infirmières québécoises exilées in Suisse, Le Temps October 17. Australian Nursing Council (2003) Letter to the Joint Standing Committee on Migration Department of House of Representatives. Accessed at www.aph.gov .au/house/committee/mig/skillmig/subs/ sub15a.pdf on 18 October 2007. Australian Nursing and Midwifery Council (2007) Position Statement Orientation of Internationally Qualified and Registered Nurses and Midwives to the Australian Healthcare Context. Accessed at www .anmc.org.au/position_statement_guidelines/ index.php on 18 October 2007. Ball J and Pike G (2004) Stepping Stones: Careers of Nurses in 2003, Royal College of Nursing, London. Buchan J and Sochalski J (2004) Nurse Migration: Trends and the Policy Context, Unpublished. Dugger C (2006) U.S. Plan to Lure Nurses May Hurt Poor Nations, NewYork Times May 24. Hawthorne L (2001) The globalisation of the nursing workforce: barriers confronting overseas qualified nurses in Australia, Nursing Inquiry 8: 213–229. ICN (2002) Career Moves and Migration: Critical Questions, International Council of Nurses, Geneva. ICN (2006) The Global Nursing Shortage: Priority Areas for Intervention, International Council of Nurses, Geneva. ICN (2007a) Position Statement: Ethical Nurse Recruitment, International Council of Nurses, Geneva. ICN (2007b) Positive Practice Environments, International Council of Nurses, Geneva. ICN (2007c) ICN Calls for Positive Practice Environments to Ensure Quality Patient Care, International Council of Nurses, Geneva. IOM (2003) World Migration 2003 – Managing Migration – Challenges and Responses for People on the Move, International Organization for Migration, Geneva. IOM (2005) World Migration 2005: Costs and Benefits
206
CN
Volume 28, Issue 1–2, April 2008
of International Migration, International Organization for Migration, Geneva. Kingma M (2006) Nurses on the Move: Migration and the Global Health Care Economy, Cornell University Press, Ithaca NY. Kingma M (2007) Nurses on the move: A global overview, Health Services Research 42: 1281–1298. Kristensen TS (1999). Challenges for research and prevention in relation to work and cardiovascular disease. Scandinavian Journal of Work, Environment and Health 25: 550–557. Martineau T, Decker K and Bundred P (2002) Briefing note on international migration of health professionals: Leveling the playing field for developing country health systems, Liverpool School of Tropical Medicine, Liverpool. NMC (2005) Statistical analysis of the register. 1 April 2004 to 31 March 2005. Report August 2005. London: Nursing and Midwifery Council. Accessed at http://www.nmcuk.org/aFrame Display.aspx?DocumentID=856 on 10 July 2006. Omeri A (2006) Workplace practices with mental health implications impacts on recruitment and retention of overseas nurses in the context of nursing shortages. Contemporary Nurse 21: 50–61 Omeri A and Atkins K (2002) Lived experiences of immigrant nurses in New South Wales, Australia: Searching for meaning. International Journal of Nursing Studies 39: 495–505. Opiniano J (2002) Over 100 Pinoy nurses exploited in UK private nursing homes. Accessed at http://cy berdyaryo.com/features/f2002_0325_04.htm on 5 January 2004. Parrish C and Pickersgill F (2005) Home office considers special visa to support overseas nurses, Nursing Standard 19: 12. Payne L (2003) Differing viewpoints on the issue of overseas nurses, Nursing Times 99: 15. Timur S (2000) Changing Trends and major issues in international migration: An overview of the UNESCO programmes. International Migration 165: 255–269. UN (2006) International migration facts and figures. Accessed at http://www.un.org/esa/popula tion/hldmigration/Text/Migration_factsheet.pdf on 18 July 2006. WHO (2006) The World Health Report 2006 –Working together for health,World Health Organization, Geneva.
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 207
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 207–210.
CN
EPILOGUE Advancing transcultural nursing through collaboration
AKRAM OMERI PhD, RN, CTN, FRCNA
Guest Editor Advances in Contemporary Transcultural Nursing Adjunct Associate Professor University of Western Sydney School of Nursing Sydney NSW, Australia
C
ollaboration is evident in today’s organisational, government and business life (Huxham & Vangen 2000) and skills to work across boundaries and to form alliances and partnerships are sought in today’s leaders. The healthcare arena is no different and the concept of boundaries to be crossed is implicit in the very nature of transcultural nursing. Successfully negotiated partnerships, coalitions and collaborations between participating healthcare groups are at the heart of advancing transcultural nursing knowledge. Extending the healthcare research capacity and capability beyond national borders and across professions through global collaborative endeavours spreads the work load and accelerates the production of knowledge (Pearson 2007) for nursing and other disciplines. Such desirable outcomes can result from effective collaborative efforts. Most countries in today’s world require quality health care interventions and practices that can be justified or based on research evidence of superior efficacy and efficiency. Responsibility
for providing such interventions and practices lies with the health care professionals who are looked to for the development of such interventions and the provision of guidance for best practices. Most countries also have difficulty in reconciling the increasing demand for the health care influenced by the speedy international knowledge exchange via the World Wide Web and the imperative of doing more with less as resources become scarcer. These factors combined with the understanding that most ‘nations and cultures are more alike than they are different’ (Pearson 2007: 69) suggest that greater collaboration on a global level would be productive and beneficial to all partners in a collaborative effort.
Essentials of a successful collaborative effort Effective collaboration is premised upon setting worthwhile goals of mutual benefit to consumers, service providers and other stake holders. It means achieving the desired outcomes by reducing or removing boundaries that impede the realisation of goals that benefit consumers and others. Collaboration involves joint effort and implies joint ownership (Linden 2002) for all partners and means the commitment of each to the goals of an enterprise/project to gain worthwhile benefits. Essential to a collaborative endeavour is a clear expression, understood and agreed by all parties in the alliance, of the joint purpose of the collaborative effort, its goals and objectives Volume 28, Issue 1–2, April 2008
CN
207
CNJ 28_1_2_internal.qxd
CN
14/07/2008
12:50 PM
Page 208
Akram Omeri
(Clegg et al 2005 cited in Brown et al 2006) and the development of a strong sense of common purpose. In our joint collaboration, as guest editors, we adopted the goal of transcultural nursing in order ‘to prepare a new generation of nurses who would be knowledgeable, sensitive, competent and safe to care for people with different and similar lifeways, values, beliefs, and practices in meaningful, explicit, and beneficial ways’ (Leininger & McFarland 2002: 6). A sense of common purpose underpins the development of strong, balanced relationships, based on trust and respect, between the partners. A key element in collaborative endeavours is effective communication and the development of strategies to ensure shared decision making (Kantar 1994). Successful development of an alliance also depends upon engaging the best possible people in the task with the authority and autonomy to speak (Huxham & Vangen 2000). It also requires time and sufficient resources to establish a project and to sustain it (Huxham 1996a, 1996b; Linden 2002).
Collaborative challenge Transcultural nurses recognise that we live in a multicultural world and that ‘all health care must be transculturally based to serve people appropriately from different cultures in the world’ (Leininger 1995: 681). The challenge is to provide research based transcultural knowledge to guide practice and to be effective in helping others and for the development of transcultural education of clinicians and faculty. As Leininger (Leininger & McFarland 2002: 578) has identified that it is the coming generation of nurses, who experience cultural diversity in their daily interactions that see the need for transcultural nursing knowledge; they turn to their educators for knowledge to assist them in their practice. As Leininger (Leininger & McFarland 2002: 7) has stated: ‘Nursing students expect their faculty to be knowledgeable and competent in transcultural nursing so they 208
CN
Volume 28, Issue 1–2, April 2008
will be effectively guided in their practice.’ Leininger has also identified that the challenge is to prepare students who are ‘knowledgeable, sensitive, competent, and safe to care for people with different or similar lifeways, values, beliefs, and practices in meaningful, explicit, and beneficial ways.’ This challenge can only be met if faculty are themselves transculturally qualified and prepared to contribute, on the one hand, to the development of transcultural knowledge and, on the other, to teach it to their students to assist them to meet the pressing demands for care that is culturally safe, meaningful and effective. Leininger predicted that ‘by the year 2020 more nurses will be prepared in graduate transcultural nursing studies which will facilitate meeting consumer expectations and transcultural nursing education and practice goals’ (Leininger & McFarland 2002: 578). Nursing in Australia in recent years has much to be proud of given the immense changes in nursing practice and education it has embraced and sustained, and the developing and growing body of nursing knowledge through research concomitant with the higher education of nurses (Halcomb, Patterson & Davidson 2006).The future development of nursing still has numerous challenges ahead. These challenges are the globalisation of health care, and the contemporary demands on health care (Pearson 2007). In response to these challenges transcultural collaborative effort is called for from the nursing profession. As Pearson (2007) has noted international collaboration is not well established in nursing. Much of nursing research is small in scale and local in application which severely limits its capacity to make a substantive contribution to advancing nursing science. A much greater contribution could be made to global health problems by nursing science through the medium of transcultural concepts. It remains for us in the coming decade to become more global and strategic in our thinking and research efforts, to seek and nurture research across national
CNJ 28_1_2_internal.qxd
14/07/2008
12:50 PM
Page 209
Epilogue: Advancing transcultural nursing through collaboration
CN
boundaries in collaborative partnerships, not strong, balanced relationships, based on trust only with other nurses but also with other pro- and respect, good and effective communication, and a shared decision-making as stated by (Kanfessions. tar 1994) essential in the success of this collaborative plan. Our commitment Our association dates back to the early As transcultural nurses our pursuit of excellence continues as a major objective in the transcultur- 1990s, two decades ago, when we met during al nursing journey by our continued leadership the first joint venture, attending the first tranin research and education informing practice at scultural nursing theory conference at Madonna the highest levels and sharing such worldwide University, Livonia, Michigan. At the time we knowledge across boundaries. It is our commit- were both pursuing graduate studies in transment to continue, and grow, as key participants cultural nursing with mentorship from Dr in contributing to the profession of nursing, and Madeleine Leininger. Since then, our mutual to advocate for the culturally meaningful and interests in transcultural nursing have continued congruent/competent health care needs of to grow.We have continued working collaborathe sick and well, to promote social justice and tively to strengthen and advance transcultural human rights of people towards equality of nursing knowledge through education, research access to health and welfare services, and health and leadership. As part of our collaboration, we have travas a right not privilege of all. This Contemporary Nurse special issue on eled to joint transcultural nursing conferences transcultural nursing, Advances in Contemporary and educational activities in Australia and USA Transcultural Nursing, 2nd edition (ISBN 978- as well as other countries, on numerous occa0-9757710-5-1) is one major collaborative sions. We have also been actively involved as endeavour aiming to advance shared and evi- members of committees of the Transcultural dence-based transcultural nursing knowledge Nursing Society including Leininger Award toward improving care in culturally meaningful Committee, Certifications Committee and the ways to clients and nurses. It has taken two Nomination Committee of the Transcultural years of planning, and organisation to bring this Nursing Society. In addition to conferencing, we have consultcollection of research-based transcultural nursing knowledge in the volume of Contemporary ed and collaborated in the design and teaching Nurse in two issues which could be shared glob- strategies for the development and delivery ally. This volume provides a collection of fresh of courses in transcultural nursing. We have ideas and research in transcultural nursing edu- exchanged ideas, philosophies, pathways of how cation, research and practice in diverse con- best to deliver the message of transcultural nursing for students and faculty in BN, MN, texts. We, as guest editors, are both certified tran- PhD as well as in continuing education proscultural nurse specialist and scholars, mentored grams, in diverse contexts and in culturally and by the Founder of the discipline of transcultural educationally meaningful ways. We have sought ways of advancing transculnursing, Madeleine Leininger, from culturally diverse backgrounds, worlds apart. Having had tural nursing through research, conference previous joint partnership in a number of collab- presentation and joint projects. Joint guest editorative projects in Australia, USA and other ing for this Contemporary Nurse special issue in countries, our collaboration in this major project transcultural nursing, Advances in Contemporary was well advanced. From the early planning Advances in Transcultural Nursing, 2nd edition, has stages, we were assured to possess qualities of been a major joint commitment in collaboration
Volume 28, Issue 1–2, April 2008
CN
209
CNJ 28_1_2_internal.qxd
CN
30/07/2008
9:50 PM
Page 210
Akram Omeri
across borders, reflecting our latest international collaboration. We have consulted online via email and telephone in order to compare our views on editing and suitability of manuscripts for this special issue. We guest editors, are well advanced in our collaborative endeavours. Plans are in place for two joint projects including; Collaboration in supervision of post-graduate nursing students online and Nurse practitioners and their roles in rural– remote areas. Nurses are realising that what we teach and how we care for people necessitates having transcultural nursing knowledge and skills to be effective and helpful to others. Living in a multicultural world challenges nurses to understand trends and cultural realities. Meeting the challenge will be greatly facilitated by collaborative effort and shared endeavour in the discovery of transcultural knowledge. Leininger has stated that by 2020: ‘all health care must be transculturally based to serve people appropriately from different cultures in the world’ (Leininger 1995 cited in Leininger & McFarland 2002: 577). In a multicultural world the challenge for the health professions and the systems that support them, is to ensure enough health professionals are available with the skills, knowledge and attitudes to provide culturally
meaningful and safe care. When this comes to pass, Leininger’s prediction that: ‘Transcultural nursing will continue to soar to many places in the world in the 21st century to serve humanity’ (Leininger 1960 cited in Leininger & McFarland, 2002: 577) will be realised.
References Brown D,White J and Leibbrandt L (2006) Collaborative partnership for nursing faculties and health service providers: what can nursing learn from business literature? Journal of Nursing Management 14: 170–179. Clegg S, Kronberger M and Pitsis T (2005) Managing and Organizations:An introduction to theory and practice. Sage Publications, London. Halcomb E, Patterson E and Davidson P (2006) Evolution of practice nursing in Australia, Journal of Advanced Nursing 55: 376–388. Huxham C (Ed) (1996a) Creating Collaborative Advantage, Sage Publications, London. Huxham C (1996b) Collaboration and collaborative advantage. In Huxham C (Ed) Creating Collaborative Advantage, pp 1–18, Sage, London, UK. Huxham C and Vangan S (2000) Ambiguity, complexity and dynamics in the membership of collaboration. Human Relations 53: 771–809. Kantar R (1994) Collaborative advantage:The art of alliances. Harvard Business Review 72: 142–149. Leininger MM and McFarland M (2002) Transcultural Nursing Concepts,Theories, Research & Practice, 3rd edn, McGraw Hill, New York. Leininger MM (1990) Ethical and Moral Dimensions of Care,Wayne State Press: Detroit MI. Linden R (2002) A framework for collaborating, Public Manager 31: 3–7. Pearson A (2007) Editorial: Exploiting the potential of international collaboration in nursing, International Journal of Nursing Practice 13: 69.
• • • C A L L F O R PA P E R S • • • I NTERNATIONAL J OURNAL
OF
M ULTIPLE R ESEARCH A PPROACHES
Indigenous Research Methods Volume 4 Issue 1 • April 2010 • Special Issue DEADLINE FOR MANUSCRIPT SUBMISSIONS: 30 April 2009 Submissions are welcome from indigenous and non-indigenous researchers and students working on approaches to Indigenous research methodologies across all the disciplines represented by the journal, including (but not limited to) Education, Health, Management, Psychology, Sociology, Social Work, Development Policy and Political Science. Authors are invited to send their abstract in advance of submission to co-Guest Editor, Dr Karen Martin:
[email protected]; tel. +61-2-66203610 Submissions following Author Guidelines on the journal website (www.ijmra.com) may be addressed to:
[email protected] eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911;
[email protected] www.e-contentmanagement.com
210
CN
Volume 28, Issue 1–2, April 2008
CNJ 28_1_2_internal.qxd
30/07/2008
9:50 PM
Page 211
Copyright © eContent Management Pty Ltd. Contemporary Nurse (2008) 28: 211–212.
CN
BOOK REVIEWS
Culture Care Diversity and Universality: A Worldwide Nursing Theory, 2nd Edition Leininger MM and McFarland MR (eds) (2006) Jones and Bartlett, Sudbury; ISBN 0-7637-3437-3; PB; xviii + 413 pp;AUD 71.00 R E V I E W E R RICK ZOUCHA Associate Professor, School of Nursing Duquesne University Pittsburgh, Pennsylvania
T
his book is the second edition based on a lifetime of work and the continued development of the 1991 edition. It is appropriate for beginning nursing students, graduate students and experienced nurse researchers interested in theory development and transcultural nursing research. The 16 chapters include a very in-depth introduction and description of culture care diversity and universality theory, along with the evolution of the theory and ethnonursing research method. The first three chapters and last chapter in the book deal with the theory, research method, globalisation of transcultural nursing theory and research, and predictions for the future. Eight chapters deal directly with the utilisation of the ethnonursing research method as findings and four chapters discuss the use of the theory in
nursing administration, clinical application, and indirectly nursing education. The book uses respected scholars in the field to present the application of the theory and findings using the research method. The authors do a good job of articulating the scope of the book through the foundational chapters related to the theory and research method that is unique to nursing and specifically developed to understand and discover phenomena of interest to nursing. Overall, the chapters that follow the foundational chapters assist the reader in understanding the relationship to the theory in practice, administration and education, as well as the rigor involved in the research process specific to the theory and research method. The authors also make a very clear connection to the theory and research method for use in discovery of culture care phenomena in nursing globally. The book could have been laid out differently by grouping the chapters using the theory in nursing, followed by the research chapters. There is relevance in using classic work to articulate the use of the theory and research method; however, presenting contemporary work could advance the continued development of the theory and research method. Presenting studies using the research method with large immigrant populations across the globe such as Mexican, or sub-cultures such as gays and lesbians, would be beneficial for future editions.
If you have a book for review, or would like to submit a review, please contact: Dr Merri Paech Book Reviews Editor, Contemporary Nurse Division of Health Sciences, University of South Australia, North Terrace SA 5000 E-mail:
[email protected]
Volume 28, Issue 1–2, April 2008
CN
211
CNJ 28_1_2_internal.qxd
CN
30/07/2008
9:50 PM
Page 212
Book reviews
Transcultural Concepts in Nursing Care, 5th Edition Andrews M and Boyle J (2008) Wolters Kluwer Health/LippincottWilliams & Wilkins, Philadelphia; ISBN 9780 7817 9037 6; PB; xx + 487 pp;AUD 82.50 R E V I E W E R SANDRA J MIXER Assistant Professor of Nursing Middle Tennessee State University Murfreesboro TN
A
s the world becomes increasingly multicultural, the fifth edition of Andrews’ and Boyle’s well-known transcultural nursing text continues to synthesise transcultural theories, models, and research to facilitate culturally congruent and competent nursing care.This comprehensive text focuses on application of transcultural nursing knowledge to nursing practice encompassing the care of individuals, families, groups, communities, and institutions across the lifespan. Rather than memorising a laundry list of cultural groups’ attributes, Andrews and Boyle purport that through cultural assessment and critical thinking, nurses throughout their professional careers will be able to meet the culture care needs of diverse people.
The book is divided into four parts: historical and theoretical foundations of transcultural nursing; transcultural nursing across the lifespan; nursing in multicultural health care settings; and contemporary challenges in transcultural nursing. With its focus on application to nursing practice, each chapter includes case studies and learning activities based on each author’s actual clinical encounters. New features in this edition are boxes containing evidenced based practice research studies to assist the reader in applying knowledge to practice. The chapters related to creating culturally competent organisations and cultural diversity in the health care workforce are especially useful for students and nurses who may embrace transcultural care of diverse patients and families and yet, may not have considered how to apply this knowledge to working with diverse colleagues.The text emphasises the importance of creating an organisational environment where cultural similarities and differences are embraced and may be crucial for facilitating culturally congruent and competent care. This comprehensive text provides an excellent resource for nursing practice and is useful for nursing students, nurses, educators, researchers, and administrators. Andrews and Boyle bring together theory, research and practice to support nurses in their quest to provide culturally competent and congruent care.
• • • C A L L F O R PA P E R S • • • A DVANCES
IN
C ONTEMPORARY
M E N TA L H E A LT H N U R S I N G – S E C O N D E D I T I O N Guest editors: Nicholas Procter, School of Nursing and Midwifery, University of South Australia, Angela Frederick Amar, William F. Connell School of Nursing, Boston College, Chestnut Hill MA, and Chang Kam Hock, Department of Nursing Faculty of Medicine and Health Sciences, University Malaysia Sarawak
DEADLINE FOR MANUSCRIPT SUBMISSIONS: 2 March 2009 A special issue of Contemporary Nurse, volume 34 issue 1, publishing December 2009 ISBN 978-0-9775242-6-6; iv+124 pages; softcover More information: http://www.contemporarynurse.com/archives/vol/34/issue/1/call/
eContent Management Pty Ltd, PO Box 1027, Maleny QLD 4552, Australia Tel.: +61-7-5435-2900; Fax. +61-7-5435-2911
[email protected]; www.e-contentmanagement.com
212
CN
Volume 28, Issue 1–2, April 2008
e C ontent
PTY
management LTD
