Art & science research
Recognising and respecting patients’ cultural diversity McClimens A et al (2014) Recognising and respecting patients’ cultural diversity. Nursing Standard. 28, 28, 45-52. Date of submission: July 16 2013; date of acceptance: September 20 2013.
Abstract Aim To explore nursing students’ experiences of caring for patients from different and often unfamiliar cultural backgrounds. Method Focus group discussions were conducted with nursing students from mental health, learning disability and adult nursing in one university, to obtain qualitative information about areas of difficulty in providing culturally competent care. Findings Nursing students expressed difficulties and challenges meeting the cultural needs of patients, with particular focus on issues related to language, food and gender. Conclusion Nursing students need to prepare for work in a culturally diverse healthcare setting and should receive education and training in this area to ensure ongoing personal and professional development.
Authors Alex McClimens Senior research fellow, Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield. Jacqui Brewster Senior lecturer, Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield. Robin Lewis Senior lecturer, Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield. Correspondence to: [email protected]
Keywords Cultural competence, cultural diversity, nursing students, qualitative study, research
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WITH AN INCREASINGLY culturally diverse population, it is essential that nurses are adequately prepared for and able to work with patients in a way that recognises and respects their diversity. Cultural competence in nursing has been defined as ‘a formal area of study and practice focused on comparative holistic culture care, health, and illness patterns of people with respect to differences and similarities in their cultural values, beliefs and lifeways with the goal to provide culturally congruent, competent and compassionate care’ (Leininger 1997). There are several models describing cultural competence. The Purnell Model for Cultural Competence (Purnell 2000) comprises 12 domains as shown in Table 1. Purnell (2000) described the model as ‘an ethnographic approach to promote cultural understanding about the human situation during times of illness, wellness, and health promotion’. According to Campinha-Bacote (2002) cultural competence has five interdependent constructs: Cultural awareness – self-examination and in-depth exploration of one’s own cultural and professional background. Cultural knowledge – seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Cultural skill – ability to collect relevant cultural data about the person’s presenting problem, as well as accurately performing a culturally-based physical assessment. Cultural encounters – encouraging the healthcare professional to engage in cross-cultural interactions with people from culturally diverse backgrounds. Cultural desire – motivation of the healthcare professional to want to, rather than have to, engage in becoming culturally aware, knowledgeable and skilful, and familiar with cultural encounters. Newman-Giger and Davidhizar (2004) suggested a six-stage process, which takes account of ‘communication, time, space, social organization, environmental control, and biological variations march 12 :: vol 28 no 28 :: 2014 45
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Art & science research [which] provide a framework for patient assessment and from which culturally sensitive care can be designed’. In a concept analysis of the term cultural competence, Burchum (2002) identified five attributes comprising cultural awareness, cultural knowledge, cultural understanding, cultural sensitivity and cultural skill, which the practitioner must engage with to demonstrate cultural competence. In the UK in the 1990s, academic activity drew attention to the relative inexperience of clinical staff in caring for patients from culturally diverse backgrounds (Lock 1992, Kreps and Kunimoto 1994, Robinson 1998, Henley and Schott 1999). However, with an increasingly culturally diverse population, it is essential that healthcare professionals are prepared to work with and meet the needs of all patients to provide equitable care. The Office for National Statistics (2003) reported that the number of people in the UK from an ethnic group other than white, rose by 53% between 1991 and 2001, from 3.1 million to 4.6 million respectively. Since then, the non-white population in the UK has increased further. Figures from the Centre on Dynamics of Ethnicity (2013) show that between 1991 and 2011 this population more than doubled in size from three million to seven million or 14% of the total UK population.
Background The NHS Constitution (Department of Health 2013) claims that ‘the NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights’. Despite this, some individuals from ethnic minority communities experience additional social challenges such as isolation, poor housing, difficulties accessing services that meet their cultural, religious and spiritual needs, and a lack of health and social care workers who have the skills to recognise and understand these needs and can communicate with these individuals in their own language (Hatton 2002, Pawson et al 2005, Raghavan et al 2009). The authors’ interest in cultural diversity and healthcare practice arose from discussions with students undertaking a combined learning disability/social work qualification. From their practice placements, the students were increasingly aware of the ethnic diversity of the local population. Across South Yorkshire, the Pakistani community, for example, forms the single largest group from all black and ethnic minority communities and in Sheffield, around 45% of people with a learning disability are from the Pakistani community (NHS Sheffield 2008). Therefore, it would seem that healthcare
TABLE 1 Twelve domains of the Purnell Model for Cultural Competence Domain
Explanation
Overview/heritage
Issues surrounding the individual’s country of origin, migrant status, education and occupation.
Communication
Linguistic competence, and other non-verbal and culturally-oriented means of communicating.
Family roles and organisation
Attitudes to gender, ageing and marital status.
Workforce issues
Autonomy and assimilation into local practices.
Biocultural ecology
Physical ethnic differences and the influence of hereditary traits.
High-risk behaviours
Cultural influence on locally proscribed practices, for example the use of khat (a mild herbal stimulant) by some Somali communities.
Nutrition
Food choices, rituals and taboos.
Pregnancy and childbearing practices
Fertility, pregnancy and gender roles.
Death rituals
Beliefs and practices that govern attitudes and behaviours around death.
Spirituality
Religious ceremonies and practices.
Healthcare practice
Traditional, cultural and personal attitudes to one’s own health care.
Healthcare practitioner
Traditional, cultural and personal attitudes to receiving health care from a practitioner.
(Purnell 2000)
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professionals are increasingly faced with the challenge of providing care for individuals from different cultural backgrounds. With this in mind, the authors conducted a small qualitative study to identify challenges experienced by nursing students caring for patients from culturally diverse backgrounds.
Aim This study aimed to explore nursing students’ experiences of caring for patients from different and often unfamiliar cultural backgrounds.
Method The Nursing and Midwifery Council (NMC) (2010) standards for pre-registration nurse education state that students need to be prepared to work in a community which is diverse in terms of culture, race, religion and ethnicity. The document states that ‘all nurses must practise in a holistic, non-judgemental, caring and sensitive manner that avoids assumptions, supports social inclusion; recognises and respects individual choice; and acknowledges diversity’ (NMC 2010). This begins with exploring and understanding one’s own culture and experiences of working with diversity. Therefore, the authors conducted a small qualitative study using focus groups with nursing students at one university to discover whether, as described by the NMC (2010), the students were able ‘to deliver care which is informed by relevant physical, social, cultural, psychological, spiritual, genetic and environmental factors, in partnership with service users’. After gaining ethical approval to conduct the study from the faculty’s research ethics committee, the authors undertook an initial pilot focus group (Table 2). Seventeen nursing students were invited to attend directly through classroom contact, which also provided the authors with the opportunity to disseminate information about the study, participation, confidentiality and consent. Three students agreed to participate and were given a consent form to confirm their voluntary participation. Discussion within the pilot focus group lasted 30 minutes and centred on aspects of culture, health, ethnicity, race, religion and identity. The authors used a template of 18 questions to ensure that all participants were given the opportunity to offer their insights and experiences relating to the discussion topics (Box 1). During the pilot focus group, several themes emerged in relation to nursing students’ experiences of working with patients from diverse cultural backgrounds,
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including issues relating to language, food and gender. The purpose of the pilot group was to identify the main themes that could be used to direct discussion in the main focus groups and to ensure that changes could be made to the format of the discussion if further topics of interest were identified. However, no changes were necessary. Following the pilot, the authors conducted three focus groups with students from three
TABLE 2 Focus group sample Focus group
Characteristics
Pilot
1 white British male 1 African female 1 Asian female
Adult nursing
5 white British females
Mental health nursing
1 white British male 4 white British females
Learning disability nursing
3 white British females 1 Caribbean British female 1 white British male
BOX 1 Focus group questions Education: What do you get currently that prepares you for cultural awareness? What do you think you need? How, from whom, and when should the above be delivered? Can cultural sensitivity be taught? Is there a role for simulation in addressing cultural competence? Can other forms of virtual media be used? Your perspective: Do you have a value system or belief that guides your actions professionally? Is the above at odds with local policy or practice? Does your experience of delivering health care ever challenge your beliefs or values? Ethnicity: Do you see any evidence of the needs of different ethnic groups being met or not in the literature and in practice? Does ethnicity affect health? What is your experience of handling culturally sensitive issues? Do you have any sense of how patients feel about you when they are from a different background? Communication: Have you experienced difficulties with communication (sign language, foreign language)? Have you experienced any problems with a patient’s comprehension (mental health issues or learning disability)? Culture: Is there an active focus on looking out for people’s cultural needs? Is the NHS putting people first? What would improve things?
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Art & science research branches of nursing: mental health, learning disability and adult nursing. The nursing students were invited to participate in the same way as those approached to take part in the pilot focus group. Out of 127 nursing students, 15 students chose to participate in the study (table 2). Consent was obtained and students were reassured that anonymity would be maintained. There were no inclusion and exclusion criteria per se beyond a desire to keep the groups manageable in number, to ensure representation of both genders and to ensure voluntary participation (Bryman 2001, Rabiee 2004). The format of the focus groups involved nursing students being asked to describe their experiences of cultural diversity while on placement to ascertain how they managed situations that fitted broadly with the themes of language, food and gender, which arose from the pilot focus group discussion. Focus group discussions lasted approximately 30 minutes and were conducted on university premises.
Data analysis
Two of the authors (AM and JB) conducted the focus group sessions and transcribed the tape recordings before undertaking initial reading and analysis, taken here to mean the reading and re-reading of the text to discover core themes (Hsieh and Shannon 2005). From this, the authors identified three main areas for discussion: language, food and gender, which were the same as those identified in the pilot group. The transcripts were then given to another colleague (RL) who read them independently and confirmed the initial interpretation. The authors describe this as a version of content analysis, in which ‘the aim is to attain a condensed and broad description of the phenomenon, and the outcome of the analysis is concepts or categories describing the phenomenon’ (Elo and Kyngäs 2008).
Findings Language
Difficulties with shared understanding of language and culture in healthcare systems are evident worldwide (Clegg 2003, Flores 2006, Levin 2006). Fisher et al (2007) noted the potential for cultural and socio-political aspects of race to ‘contribute to the production of racial disparities in health and health care’. They suggested that ‘cultural leverage’, defined as ‘a focused strategy for improving the health of racial and ethnic communities by using their cultural practices, products, philosophies, or environments as vehicles that facilitate behaviour 48 march 12 :: vol 28 no 28 :: 2014
change of patients and practitioners’ can be used to reduce these disparities (Fisher et al 2007). In the authors’ study, it was apparent that nursing students faced similar challenges. One nursing student reflected that even though the site was considered to be a large teaching hospital in the city, and signage on the outside of the building was in English with translations for a variety of the main languages commonly used in the area, once inside the hospital ‘everything’s in English’. Mistranslation and breakdown in communication has the potential to cause harm and compromise patient safety. Divi et al (2007) claimed: ‘Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.’ Communication, however, is a two-way process and one nursing student commented that older patients on one rehabilitation ward could not understand the doctor who was not born in the UK. The student had to repeat what was said to the patients. One student also experienced difficulty understanding accents. He stated: ‘You feel rude saying “say that again… say that again”.’ Several nursing students commented on their frustrations and the expense of having to use telephone services to provide translation. However, even when a translator is available, issues may still arise, particularly in relation to the accuracy of information being communicated. One of the mental health nursing students described a situation where a person of north African origin was undergoing an assessment: ‘We needed some information. We would ask a direct question and the interpreter would have a long conversation with the service user and then the interpreter would give a one-word answer. We didn’t know if we had got the whole story. This left us wondering what had been said.’ Betancourt et al (2005) stated that: ‘The goal of cultural competence is to create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency.’ That is not to suggest that all healthcare professionals should become multi-lingual, but it does highlight the need to develop strategies to ensure that barriers to communication are minimised and do not compromise patient care and safety. Williams and Rucker (2000) found that where sociocultural
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differences between patients and care providers are not reconciled, this has negative consequences for patients, for example difficulty accessing certain procedures and treatments.
Food
Food preparation and choices are strong indicators of an individual’s cultural background, for example during Ramadan religious observance involves not eating and drinking during particular times of the day. Food etiquette and table manners are also indicators of cultural codes, which can be misread by those who do not have knowledge of that particular culture. An example of this is evident from discussions in one focus group, where one of the nursing students, a woman of African heritage, described an incident that occurred while she was on placement in a learning disability respite care facility. This involved a young Gambian man throwing away the cutlery offered at mealtime and using his fingers to eat the food. The nursing student was able to explain to her colleagues that she often ate with her hands when at home and that the young man was merely eating according to his custom. One student recalled an incident involving a patient with a ‘Muslim sounding name’ who was given the halal menu without any attempt to ascertain his preferences. This reinforces the need to address everyone’s needs on an individual basis. For example, Muslim patients on one general ward commented on the lack of variety of the food and restricted food options available to them, saying: ‘Oh great, curry and rice again!’ because that’s all they were given. One of the nursing students commented ‘…there’s a danger in making it too rule-based if everybody from a particular culture gets the same [food] like it or not’. One learning disability student had spoken to the parents of a young girl who routinely ate halal food at home. The girl’s parents understood that halal food might not always be available in community settings and they were content for their daughter to eat non-halal food in those circumstances. However, not everyone is as relaxed about their faith-based obligations. For example, there was one case of a Muslim man admitted to a psychiatric facility who was given pork products at mealtime. The nursing student reported: ‘He got very angry and upset. He was an out-of-area patient so he was not near family and he was already upset because he had been moved out of his local area. So it escalated from there and it took a lot of one-to-one time before he would trust staff... he felt things were being targeted at him when they were not.’
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The control of dietary choices can be a sensitive area for patients. People whose food intake is governed to some extent by cultural beliefs can feel that their identity is being threatened or devalued when their customs and preferences are ignored. It should be noted that food choices are not restricted to those who are from minority ethnic populations, for example Dreher and Macnaughton (2002) observed that ‘white, middle-class, vegetarians have dietary restrictions that deserve the same consideration as those of Hindus’.
Gender
Cortis (2003) discussed the need for nurses to acknowledge the significance of belonging to the dominant culture in any society. Cortis (2003) suggested that these individuals need to apply the practice of ‘cultural safety’, whereby they are aware of practices that ‘demean, diminish and disempower’ minority groups and seek instead to ‘affirm and respect’ different cultural expression. Research undertaken by Ali (2004) found that many women prefer female healthcare staff to carry out intimate care tasks irrespective of their culture, religion or ethnic origin. This may explain the situation recalled by one male nursing student who stated: ‘One woman would not acknowledge me or talk to me, but it was the same with all male staff, so maybe it was more gender based than cultural.’ One of the female adult nursing students described a scenario where an African woman was experiencing bladder retention and required catheterisation. The mentor asked the patient if it was okay if the student observed, but the patient declined. Difficulties can arise if a patient is adamant about the gender of attending clinicians. Staffing rotas are designed to meet patients’ clinical requirements, with an emphasis on achieving the requisite skill mix before considering socio-cultural balance. One nursing student described an incident that occurred during her first placement on a surgical ward: ‘I had to do some post-op checks on a Muslim woman. I was pulling the curtain back round the bed [opening the curtain] during visiting time and realised she could not be seen by men. I realised just in time, so I stopped.’ Students also talked about their concerns when caring for people from diverse cultures, with one nursing student stating: ‘You might ask the wrong thing, they may be offended. You have a fear even though you need to ask more. But also you might make assumptions and get it wrong.’ The idea that there is a right and a wrong way of providing care when cultural elements are march 12 :: vol 28 no 28 :: 2014 49
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Art & science research present seems to have the potential to inhibit some students’ interaction with patients.
Discussion The issue of cultural competence is complex and varies between settings, individuals and organisations. One nursing student commented: ‘We haven’t had actual sessions on ethnic minorities and healthcare [and] thinking about the areas that we actually go out and work in there are diverse cultures’. While this may seem like an organisational oversight, Papadopoulos et al (2004) made reference to reports by Acheson (1998) and Macpherson (1999), which suggest that neither individual training nor awareness-raising sessions will alter institutional behaviour. Papadopoulos et al (2004) stated that: ‘Failure to recognise cultural differences, a feeling that these differences are not significant or that attention to individualised care will transcend them, can result in discrimination which may be either intentional or unintended.’ A person’s upbringing will be a factor in how he or she conducts him or herself as a patient or practitioner within the healthcare setting (Seeleman et al 2009). Seeleman et al (2009) suggested that ‘factors such as religion, influences people’s perceptions of health and health care, their frames of reference, and their expectations. Awareness of how this might be of influence – instead of mere knowledge about the cultural practices or beliefs or specific ethnic groups – and an appreciation of this factor helps [practitioners] deal effectively with cultural issues’. To practise according to this perspective would mean that nursing students would need to be proactive in understanding cultural influences on all patients. For cultural competence to develop, students must be exposed to a mix of theory and practice to prepare them for the hands-on aspects of care delivery. The nursing students agreed that their work demanded cultural sensitivity, however one student remarked that it was impossible to learn everything, and that they would need to engage in independent learning alongside any teaching. This perspective is supported by Kai et al (2007), who identified that some clinicians were acutely aware of their lack of understanding of some aspects of cultural sensitivity and demonstrated anxiety about behaving in an inappropriate manner and upsetting patients. It is precisely in this area of uncertainty that the nursing students involved in the focus groups were practising. However, cultural competence involves ‘the capacity to be equally therapeutic with patients 50 march 12 :: vol 28 no 28 :: 2014
from any social context or cultural background’ (Dehrer and Macnaughton 2002). Cultural competence may be achieved through training and education that focuses on improving healthcare professionals’ awareness of the diverse cultural and religious needs of particular patient groups. Patient-centred care would also help to ensure that healthcare professionals focus on patients’ physical, social and emotional needs (Brooker 2003, Nolan et al 2004, Cambridge and Carnaby 2005). As an extension of this, Beach et al (2006) highlighted the importance of relationship-centred care to guide healthcare delivery, which is founded on four principles: Relationships in health care should include the personhood of the participants. Affect and emotion are important components of relationships in health care. Relationships in health care occur in the context of reciprocal influence. Formation and maintenance of genuine relationships in health care is morally valuable. Although these aspects are important and emphasise that relationships between patients and healthcare professionals are essential to ensure effective care delivery, one has to consider whether the clinical environment can accommodate this level of reciprocity. For example, staffing levels and a lack of people with cultural expertise and skills may mean that approaching care in this way is challenging. Johnson et al (2004) conducted a large-scale survey in the Unites States of hospital patients to ascertain whether the perceived racial and cultural differences in care could be explained by patient demographics, source of care or patient-provider communication variables. Their results revealed ‘troubling evidence that racial and ethnic minority respondents are more likely to perceive bias and lack of cultural competence when seeking treatment in the health care system overall than whites’ (Johnson et al 2004). This situation might be avoided if clinicians had greater awareness of cultural issues and the need to demonstrate sensitivity in this area. Kleinman and Benson (2006) proposed that the clinician should attempt to understand the patient perspective in much the same way as an ethnographer or anthropologist would do when visiting a foreign country. Kreuter et al (2003) discussed this with reference to the ideas of and ‘tailoring’ and ‘targeting’. Cultural tailoring refers to designing interventions that take account of individual patient preferences, while cultural targeting considers group members who share similar practices, values and beliefs. Kreuter (2003) et al suggested that individual differences
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between those who may have a similar culture can be understood because ‘although culture is shared, individuals within a given culture can have varying levels of certain cultural beliefs’. This point was supported by one of the nursing students in the focus groups who commented that in some African cultures involvement of an outside agency to provide care for a family member is seen as a failing. The nursing student went on to say that it was part of her remit to reassure these families who used respite services that this was an acceptable option. Although person-centered care is essential to meet patients’ individual needs, it is only successful when it is planned and delivered in partnership with the patient. Nursing students may benefit from role play and human patient simulation as a means of providing opportunities to rehearse practical skills in a non-threatening and safe environment. The ability to make
mistakes and learn from them is vital. Facilitated by staff skilled in addressing cultural issues, simulation and role play can help students focus on the practical cultural dynamics of the nurse-patient encounter. Any simulation and role play sessions should be supported by lectures and seminars that provide students with the underpinning knowledge and understanding to consider the wider socio-economic, political, and cultural contexts that affect patients’ abilities to access health care. Liaison with service user groups, faith groups and representatives of various cultural divisions, with the intention of incorporating their particular world view into structured classroom activity, is also advocated by the authors. Although this type of activity might only provide a superficial level of engagement, it serves as an introduction to the complex layers of diversity that nurses are likely to encounter in practice.
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Cambridge P, Carnaby S (Eds) (2005) Person Centred Planning and Care Management with People with Learning Disabilities. Jessica Kingsley Publishers, London. Campinha-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing. 13, 3, 181-184. Centre on Dynamics of Ethnicity (2013) What Makes Ethnic Group Populations Grow? Age Structures and Immigration. www.ethnicity. ac.uk/census/CoDE-Age-StructureCensus-Briefing.pdf (Last accessed: February 19 2014.) Clegg A (2003) Older South Asian patient and carer perceptions of culturally sensitive care in a community hospital. Journal of Clinical Nursing. 12, 2, 283-290.
Bryman A (2001) Social Research Methods. Oxford University Press, Oxford.
Cortis JD (2003) Culture, values and racism: application to nursing. International Nursing Review. 50, 1, 55-64.
Burchum JL (2002) Cultural competence: an evolutionary perspective. Nursing Forum. 37, 4, 5-15.
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Divi C, Koss RG, Schmaltz SP, Loeb JM (2007) Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. 19, 2, 60-67. Dreher M, Macnaughton N (2002) Cultural competence in nursing: foundation or fallacy? Nursing Outlook. 50, 5, 181-186. Elo S, Kyngäs H (2008) The qualitative content analysis process. Journal of Advanced Nursing. 62, 1, 107-115. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA (2007) Cultural leverage: interventions using culture to narrow racial disparities in health care. Medical Care Research and Review. 64, Suppl 5, 243S-282S. Flores G (2006) Language barriers to health care in the United States. New England Journal of Medicine. 355, 3, 229-231. Hatton C (2002) People with intellectual disabilities from ethnic minority communities in the United States and the United Kingdom. International Review of Research in Mental Retardation. 25, 209-239.
Henley A, Schott J (1999) Culture, Religion and Patient Care in A Multi-Ethnic Society: A Handbook for Professionals. Age Concern Books, London. Hsieh HF, Shannon SE (2005) Three approaches to qualitative content analysis. Qualitative Health Research. 15, 9, 1277-1288. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA (2004) Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of General Internal Medicine. 19, 2, 101-110. Kai J, Beavan J, Faull C, Dodson L, Gill P, Beighton A (2007) Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study. PLoS Medicine. 4, 11, e323. Kleinman A, Benson P (2006) Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine. 3, 10, e294. Kreps GL, Kunimoto EN (1994) Effective Communication in
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Art & science research Limitations The study was devised and conducted by three white, middle class academics, which may have affected the interpretation of data. Another limitation may have been the small sample size and inclusion of participants from particular branches of nursing in the focus groups, which may affect the generalisability of the findings. Ethnic minorities were also mainly represented by patients from the Muslim community, however this reflects the demographic of the region.
Conclusion Recognising and respecting cultural diversity is essential to ensure that individual patients’ needs are met. Nursing students should receive training and education to ensure that they are able to provide care in an increasingly culturally diverse healthcare environment. Issues surrounding cultural sensitivity
Multicultural Health Care Settings. Sage, London. Kreuter MW, Lukwago SN, Bucholtz DC, Clark EM, Sanders-Thompson V (2003) Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Education and Behaviour. 30, 2, 133-146. Leininger M (1997) Transcultural nursing research to transform nursing education and practice: 40 years. Image: Journal of Nursing Scholarship. 29, 4, 341-347. Levin ME (2006) Language as a barrier to care for Xhosa-speaking patients at a South African paediatric teaching hospital. South African Medical Journal. 96, 10, 1076-1079. Lock DC (1992) Increasing Multicultural Understanding. London, Sage. Macpherson W (1999) The Stephen Lawrence Inquiry. Report of an
Inquiry by Sir William Macpherson of Cluny. www.archive.officialdocuments.co.uk/document/ cm42/4262/4262.htm (Last accessed: February 19 2014.) Newman-Giger J, Davidhizar R (2004) Transcultural Nursing: Assessment and Intervention. Fourth edition. Mosby, St. Louis MO. NHS Sheffield (2008) Sheffield Director of Public Health Report 2008. www.publichealthsheffield 2008.nhs.uk/learningdisabilities/ ld1.php (Last accessed: February 19 2014.) Nolan MR, Davies S, Brown J, Keady J, Nolan J (2004) Beyond person-centred care: a new vision for gerontological nursing. Journal of Clinical Nursing. 13, 3a, 45-53. Nursing and Midwifery Council (2010) Standards for Pre-Registration Nursing Education. standards.nmc-uk. org/PublishedDocuments/ Standards%20for%20preregistration%20nursing%20
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and diversity should form part of pre-registration nurse education and should be reinforced throughout the nurse’s career to ensure personal and professional development, and the delivery of culturally competent and equitable health care NS See student life page 66
IMPLICATIONS FOR PRACTICE Cultural competence is essential in an increasingly culturally diverse healthcare setting. Patient-centered care should be adopted by all healthcare professionals to ensure that individuals’ needs are recognised and met. Nursing students require preparation during pre-registration education and support while on clinical placement to deal with the challenges of providing care for people from diverse and often unfamiliar backgrounds.
education%2016082010.pdf (Last accessed: February 19 2014.)
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Papadopoulos I, Tilki M, Lees S (2004) Promoting cultural competence in health care through a research-based intervention in the UK. Diversity in Health and Social Care. 1, 2, 107-115. Pawson N, Raghavan R, Small N, Craig S, Spencer M (2005) Social inclusion, social networks and ethnicity: the development of the social inclusion interview schedule for young people with learning disabilities. British Journal of Learning Disabilities. 33, 1, 15-22. Purnell L (2000) A description of the Purnell Model for Cultural Competence. Journal of Transcultural Nursing. 11, 1, 40-46. Rabiee F (2004) Focus-group interview and data analysis.
Robinson L (1998) ‘Race’, Communication and the Caring Professions. Open University Press, Buckingham. Seeleman C, Suurmond J, Stronks K (2009) Cultural competence: a conceptual framework for teaching and learning. Medical Education. 43, 3, 229-237. Williams DR, Rucker TD (2000) Understanding and addressing racial disparities in health care. Health Care Financing Review. 21, 4, 75-90.
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Recognising and respecting patients’ cultural diversity McClimens A et al (2014) Recognising and respecting patients’ cultural diversity. Nursing Standard. 28, 28, 45-52. Date of submission: July 16 2013; date of acceptance: September 20 2013.
Abstract Aim To explore nursing students’ experiences of caring for patients from different and often unfamiliar cultural backgrounds. Method Focus group discussions were conducted with nursing students from mental health, learning disability and adult nursing in one university, to obtain qualitative information about areas of difficulty in providing culturally competent care. Findings Nursing students expressed difficulties and challenges meeting the cultural needs of patients, with particular focus on issues related to language, food and gender. Conclusion Nursing students need to prepare for work in a culturally diverse healthcare setting and should receive education and training in this area to ensure ongoing personal and professional development.
Authors Alex McClimens Senior research fellow, Centre for Health and Social Care Research, Sheffield Hallam University, Sheffield. Jacqui Brewster Senior lecturer, Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield. Robin Lewis Senior lecturer, Faculty of Health & Wellbeing, Sheffield Hallam University, Sheffield. Correspondence to: [email protected]
Keywords Cultural competence, cultural diversity, nursing students, qualitative study, research
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WITH AN INCREASINGLY culturally diverse population, it is essential that nurses are adequately prepared for and able to work with patients in a way that recognises and respects their diversity. Cultural competence in nursing has been defined as ‘a formal area of study and practice focused on comparative holistic culture care, health, and illness patterns of people with respect to differences and similarities in their cultural values, beliefs and lifeways with the goal to provide culturally congruent, competent and compassionate care’ (Leininger 1997). There are several models describing cultural competence. The Purnell Model for Cultural Competence (Purnell 2000) comprises 12 domains as shown in Table 1. Purnell (2000) described the model as ‘an ethnographic approach to promote cultural understanding about the human situation during times of illness, wellness, and health promotion’. According to Campinha-Bacote (2002) cultural competence has five interdependent constructs: Cultural awareness – self-examination and in-depth exploration of one’s own cultural and professional background. Cultural knowledge – seeking and obtaining a sound educational foundation about diverse cultural and ethnic groups. Cultural skill – ability to collect relevant cultural data about the person’s presenting problem, as well as accurately performing a culturally-based physical assessment. Cultural encounters – encouraging the healthcare professional to engage in cross-cultural interactions with people from culturally diverse backgrounds. Cultural desire – motivation of the healthcare professional to want to, rather than have to, engage in becoming culturally aware, knowledgeable and skilful, and familiar with cultural encounters. Newman-Giger and Davidhizar (2004) suggested a six-stage process, which takes account of ‘communication, time, space, social organization, environmental control, and biological variations march 12 :: vol 28 no 28 :: 2014 45
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Art & science research [which] provide a framework for patient assessment and from which culturally sensitive care can be designed’. In a concept analysis of the term cultural competence, Burchum (2002) identified five attributes comprising cultural awareness, cultural knowledge, cultural understanding, cultural sensitivity and cultural skill, which the practitioner must engage with to demonstrate cultural competence. In the UK in the 1990s, academic activity drew attention to the relative inexperience of clinical staff in caring for patients from culturally diverse backgrounds (Lock 1992, Kreps and Kunimoto 1994, Robinson 1998, Henley and Schott 1999). However, with an increasingly culturally diverse population, it is essential that healthcare professionals are prepared to work with and meet the needs of all patients to provide equitable care. The Office for National Statistics (2003) reported that the number of people in the UK from an ethnic group other than white, rose by 53% between 1991 and 2001, from 3.1 million to 4.6 million respectively. Since then, the non-white population in the UK has increased further. Figures from the Centre on Dynamics of Ethnicity (2013) show that between 1991 and 2011 this population more than doubled in size from three million to seven million or 14% of the total UK population.
Background The NHS Constitution (Department of Health 2013) claims that ‘the NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual that it serves and must respect their human rights’. Despite this, some individuals from ethnic minority communities experience additional social challenges such as isolation, poor housing, difficulties accessing services that meet their cultural, religious and spiritual needs, and a lack of health and social care workers who have the skills to recognise and understand these needs and can communicate with these individuals in their own language (Hatton 2002, Pawson et al 2005, Raghavan et al 2009). The authors’ interest in cultural diversity and healthcare practice arose from discussions with students undertaking a combined learning disability/social work qualification. From their practice placements, the students were increasingly aware of the ethnic diversity of the local population. Across South Yorkshire, the Pakistani community, for example, forms the single largest group from all black and ethnic minority communities and in Sheffield, around 45% of people with a learning disability are from the Pakistani community (NHS Sheffield 2008). Therefore, it would seem that healthcare
TABLE 1 Twelve domains of the Purnell Model for Cultural Competence Domain
Explanation
Overview/heritage
Issues surrounding the individual’s country of origin, migrant status, education and occupation.
Communication
Linguistic competence, and other non-verbal and culturally-oriented means of communicating.
Family roles and organisation
Attitudes to gender, ageing and marital status.
Workforce issues
Autonomy and assimilation into local practices.
Biocultural ecology
Physical ethnic differences and the influence of hereditary traits.
High-risk behaviours
Cultural influence on locally proscribed practices, for example the use of khat (a mild herbal stimulant) by some Somali communities.
Nutrition
Food choices, rituals and taboos.
Pregnancy and childbearing practices
Fertility, pregnancy and gender roles.
Death rituals
Beliefs and practices that govern attitudes and behaviours around death.
Spirituality
Religious ceremonies and practices.
Healthcare practice
Traditional, cultural and personal attitudes to one’s own health care.
Healthcare practitioner
Traditional, cultural and personal attitudes to receiving health care from a practitioner.
(Purnell 2000)
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professionals are increasingly faced with the challenge of providing care for individuals from different cultural backgrounds. With this in mind, the authors conducted a small qualitative study to identify challenges experienced by nursing students caring for patients from culturally diverse backgrounds.
Aim This study aimed to explore nursing students’ experiences of caring for patients from different and often unfamiliar cultural backgrounds.
Method The Nursing and Midwifery Council (NMC) (2010) standards for pre-registration nurse education state that students need to be prepared to work in a community which is diverse in terms of culture, race, religion and ethnicity. The document states that ‘all nurses must practise in a holistic, non-judgemental, caring and sensitive manner that avoids assumptions, supports social inclusion; recognises and respects individual choice; and acknowledges diversity’ (NMC 2010). This begins with exploring and understanding one’s own culture and experiences of working with diversity. Therefore, the authors conducted a small qualitative study using focus groups with nursing students at one university to discover whether, as described by the NMC (2010), the students were able ‘to deliver care which is informed by relevant physical, social, cultural, psychological, spiritual, genetic and environmental factors, in partnership with service users’. After gaining ethical approval to conduct the study from the faculty’s research ethics committee, the authors undertook an initial pilot focus group (Table 2). Seventeen nursing students were invited to attend directly through classroom contact, which also provided the authors with the opportunity to disseminate information about the study, participation, confidentiality and consent. Three students agreed to participate and were given a consent form to confirm their voluntary participation. Discussion within the pilot focus group lasted 30 minutes and centred on aspects of culture, health, ethnicity, race, religion and identity. The authors used a template of 18 questions to ensure that all participants were given the opportunity to offer their insights and experiences relating to the discussion topics (Box 1). During the pilot focus group, several themes emerged in relation to nursing students’ experiences of working with patients from diverse cultural backgrounds,
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including issues relating to language, food and gender. The purpose of the pilot group was to identify the main themes that could be used to direct discussion in the main focus groups and to ensure that changes could be made to the format of the discussion if further topics of interest were identified. However, no changes were necessary. Following the pilot, the authors conducted three focus groups with students from three
TABLE 2 Focus group sample Focus group
Characteristics
Pilot
1 white British male 1 African female 1 Asian female
Adult nursing
5 white British females
Mental health nursing
1 white British male 4 white British females
Learning disability nursing
3 white British females 1 Caribbean British female 1 white British male
BOX 1 Focus group questions Education: What do you get currently that prepares you for cultural awareness? What do you think you need? How, from whom, and when should the above be delivered? Can cultural sensitivity be taught? Is there a role for simulation in addressing cultural competence? Can other forms of virtual media be used? Your perspective: Do you have a value system or belief that guides your actions professionally? Is the above at odds with local policy or practice? Does your experience of delivering health care ever challenge your beliefs or values? Ethnicity: Do you see any evidence of the needs of different ethnic groups being met or not in the literature and in practice? Does ethnicity affect health? What is your experience of handling culturally sensitive issues? Do you have any sense of how patients feel about you when they are from a different background? Communication: Have you experienced difficulties with communication (sign language, foreign language)? Have you experienced any problems with a patient’s comprehension (mental health issues or learning disability)? Culture: Is there an active focus on looking out for people’s cultural needs? Is the NHS putting people first? What would improve things?
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Art & science research branches of nursing: mental health, learning disability and adult nursing. The nursing students were invited to participate in the same way as those approached to take part in the pilot focus group. Out of 127 nursing students, 15 students chose to participate in the study (table 2). Consent was obtained and students were reassured that anonymity would be maintained. There were no inclusion and exclusion criteria per se beyond a desire to keep the groups manageable in number, to ensure representation of both genders and to ensure voluntary participation (Bryman 2001, Rabiee 2004). The format of the focus groups involved nursing students being asked to describe their experiences of cultural diversity while on placement to ascertain how they managed situations that fitted broadly with the themes of language, food and gender, which arose from the pilot focus group discussion. Focus group discussions lasted approximately 30 minutes and were conducted on university premises.
Data analysis
Two of the authors (AM and JB) conducted the focus group sessions and transcribed the tape recordings before undertaking initial reading and analysis, taken here to mean the reading and re-reading of the text to discover core themes (Hsieh and Shannon 2005). From this, the authors identified three main areas for discussion: language, food and gender, which were the same as those identified in the pilot group. The transcripts were then given to another colleague (RL) who read them independently and confirmed the initial interpretation. The authors describe this as a version of content analysis, in which ‘the aim is to attain a condensed and broad description of the phenomenon, and the outcome of the analysis is concepts or categories describing the phenomenon’ (Elo and Kyngäs 2008).
Findings Language
Difficulties with shared understanding of language and culture in healthcare systems are evident worldwide (Clegg 2003, Flores 2006, Levin 2006). Fisher et al (2007) noted the potential for cultural and socio-political aspects of race to ‘contribute to the production of racial disparities in health and health care’. They suggested that ‘cultural leverage’, defined as ‘a focused strategy for improving the health of racial and ethnic communities by using their cultural practices, products, philosophies, or environments as vehicles that facilitate behaviour 48 march 12 :: vol 28 no 28 :: 2014
change of patients and practitioners’ can be used to reduce these disparities (Fisher et al 2007). In the authors’ study, it was apparent that nursing students faced similar challenges. One nursing student reflected that even though the site was considered to be a large teaching hospital in the city, and signage on the outside of the building was in English with translations for a variety of the main languages commonly used in the area, once inside the hospital ‘everything’s in English’. Mistranslation and breakdown in communication has the potential to cause harm and compromise patient safety. Divi et al (2007) claimed: ‘Language barriers appear to increase the risks to patient safety. It is important for patients with language barriers to have ready access to competent language services. Providers need to collect reliable language data at the patient point of entry and document the language services provided during the patient-provider encounter.’ Communication, however, is a two-way process and one nursing student commented that older patients on one rehabilitation ward could not understand the doctor who was not born in the UK. The student had to repeat what was said to the patients. One student also experienced difficulty understanding accents. He stated: ‘You feel rude saying “say that again… say that again”.’ Several nursing students commented on their frustrations and the expense of having to use telephone services to provide translation. However, even when a translator is available, issues may still arise, particularly in relation to the accuracy of information being communicated. One of the mental health nursing students described a situation where a person of north African origin was undergoing an assessment: ‘We needed some information. We would ask a direct question and the interpreter would have a long conversation with the service user and then the interpreter would give a one-word answer. We didn’t know if we had got the whole story. This left us wondering what had been said.’ Betancourt et al (2005) stated that: ‘The goal of cultural competence is to create a healthcare system and workforce that are capable of delivering the highest quality care to every patient regardless of race, ethnicity, culture, or language proficiency.’ That is not to suggest that all healthcare professionals should become multi-lingual, but it does highlight the need to develop strategies to ensure that barriers to communication are minimised and do not compromise patient care and safety. Williams and Rucker (2000) found that where sociocultural
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differences between patients and care providers are not reconciled, this has negative consequences for patients, for example difficulty accessing certain procedures and treatments.
Food
Food preparation and choices are strong indicators of an individual’s cultural background, for example during Ramadan religious observance involves not eating and drinking during particular times of the day. Food etiquette and table manners are also indicators of cultural codes, which can be misread by those who do not have knowledge of that particular culture. An example of this is evident from discussions in one focus group, where one of the nursing students, a woman of African heritage, described an incident that occurred while she was on placement in a learning disability respite care facility. This involved a young Gambian man throwing away the cutlery offered at mealtime and using his fingers to eat the food. The nursing student was able to explain to her colleagues that she often ate with her hands when at home and that the young man was merely eating according to his custom. One student recalled an incident involving a patient with a ‘Muslim sounding name’ who was given the halal menu without any attempt to ascertain his preferences. This reinforces the need to address everyone’s needs on an individual basis. For example, Muslim patients on one general ward commented on the lack of variety of the food and restricted food options available to them, saying: ‘Oh great, curry and rice again!’ because that’s all they were given. One of the nursing students commented ‘…there’s a danger in making it too rule-based if everybody from a particular culture gets the same [food] like it or not’. One learning disability student had spoken to the parents of a young girl who routinely ate halal food at home. The girl’s parents understood that halal food might not always be available in community settings and they were content for their daughter to eat non-halal food in those circumstances. However, not everyone is as relaxed about their faith-based obligations. For example, there was one case of a Muslim man admitted to a psychiatric facility who was given pork products at mealtime. The nursing student reported: ‘He got very angry and upset. He was an out-of-area patient so he was not near family and he was already upset because he had been moved out of his local area. So it escalated from there and it took a lot of one-to-one time before he would trust staff... he felt things were being targeted at him when they were not.’
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The control of dietary choices can be a sensitive area for patients. People whose food intake is governed to some extent by cultural beliefs can feel that their identity is being threatened or devalued when their customs and preferences are ignored. It should be noted that food choices are not restricted to those who are from minority ethnic populations, for example Dreher and Macnaughton (2002) observed that ‘white, middle-class, vegetarians have dietary restrictions that deserve the same consideration as those of Hindus’.
Gender
Cortis (2003) discussed the need for nurses to acknowledge the significance of belonging to the dominant culture in any society. Cortis (2003) suggested that these individuals need to apply the practice of ‘cultural safety’, whereby they are aware of practices that ‘demean, diminish and disempower’ minority groups and seek instead to ‘affirm and respect’ different cultural expression. Research undertaken by Ali (2004) found that many women prefer female healthcare staff to carry out intimate care tasks irrespective of their culture, religion or ethnic origin. This may explain the situation recalled by one male nursing student who stated: ‘One woman would not acknowledge me or talk to me, but it was the same with all male staff, so maybe it was more gender based than cultural.’ One of the female adult nursing students described a scenario where an African woman was experiencing bladder retention and required catheterisation. The mentor asked the patient if it was okay if the student observed, but the patient declined. Difficulties can arise if a patient is adamant about the gender of attending clinicians. Staffing rotas are designed to meet patients’ clinical requirements, with an emphasis on achieving the requisite skill mix before considering socio-cultural balance. One nursing student described an incident that occurred during her first placement on a surgical ward: ‘I had to do some post-op checks on a Muslim woman. I was pulling the curtain back round the bed [opening the curtain] during visiting time and realised she could not be seen by men. I realised just in time, so I stopped.’ Students also talked about their concerns when caring for people from diverse cultures, with one nursing student stating: ‘You might ask the wrong thing, they may be offended. You have a fear even though you need to ask more. But also you might make assumptions and get it wrong.’ The idea that there is a right and a wrong way of providing care when cultural elements are march 12 :: vol 28 no 28 :: 2014 49
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Art & science research present seems to have the potential to inhibit some students’ interaction with patients.
Discussion The issue of cultural competence is complex and varies between settings, individuals and organisations. One nursing student commented: ‘We haven’t had actual sessions on ethnic minorities and healthcare [and] thinking about the areas that we actually go out and work in there are diverse cultures’. While this may seem like an organisational oversight, Papadopoulos et al (2004) made reference to reports by Acheson (1998) and Macpherson (1999), which suggest that neither individual training nor awareness-raising sessions will alter institutional behaviour. Papadopoulos et al (2004) stated that: ‘Failure to recognise cultural differences, a feeling that these differences are not significant or that attention to individualised care will transcend them, can result in discrimination which may be either intentional or unintended.’ A person’s upbringing will be a factor in how he or she conducts him or herself as a patient or practitioner within the healthcare setting (Seeleman et al 2009). Seeleman et al (2009) suggested that ‘factors such as religion, influences people’s perceptions of health and health care, their frames of reference, and their expectations. Awareness of how this might be of influence – instead of mere knowledge about the cultural practices or beliefs or specific ethnic groups – and an appreciation of this factor helps [practitioners] deal effectively with cultural issues’. To practise according to this perspective would mean that nursing students would need to be proactive in understanding cultural influences on all patients. For cultural competence to develop, students must be exposed to a mix of theory and practice to prepare them for the hands-on aspects of care delivery. The nursing students agreed that their work demanded cultural sensitivity, however one student remarked that it was impossible to learn everything, and that they would need to engage in independent learning alongside any teaching. This perspective is supported by Kai et al (2007), who identified that some clinicians were acutely aware of their lack of understanding of some aspects of cultural sensitivity and demonstrated anxiety about behaving in an inappropriate manner and upsetting patients. It is precisely in this area of uncertainty that the nursing students involved in the focus groups were practising. However, cultural competence involves ‘the capacity to be equally therapeutic with patients 50 march 12 :: vol 28 no 28 :: 2014
from any social context or cultural background’ (Dehrer and Macnaughton 2002). Cultural competence may be achieved through training and education that focuses on improving healthcare professionals’ awareness of the diverse cultural and religious needs of particular patient groups. Patient-centred care would also help to ensure that healthcare professionals focus on patients’ physical, social and emotional needs (Brooker 2003, Nolan et al 2004, Cambridge and Carnaby 2005). As an extension of this, Beach et al (2006) highlighted the importance of relationship-centred care to guide healthcare delivery, which is founded on four principles: Relationships in health care should include the personhood of the participants. Affect and emotion are important components of relationships in health care. Relationships in health care occur in the context of reciprocal influence. Formation and maintenance of genuine relationships in health care is morally valuable. Although these aspects are important and emphasise that relationships between patients and healthcare professionals are essential to ensure effective care delivery, one has to consider whether the clinical environment can accommodate this level of reciprocity. For example, staffing levels and a lack of people with cultural expertise and skills may mean that approaching care in this way is challenging. Johnson et al (2004) conducted a large-scale survey in the Unites States of hospital patients to ascertain whether the perceived racial and cultural differences in care could be explained by patient demographics, source of care or patient-provider communication variables. Their results revealed ‘troubling evidence that racial and ethnic minority respondents are more likely to perceive bias and lack of cultural competence when seeking treatment in the health care system overall than whites’ (Johnson et al 2004). This situation might be avoided if clinicians had greater awareness of cultural issues and the need to demonstrate sensitivity in this area. Kleinman and Benson (2006) proposed that the clinician should attempt to understand the patient perspective in much the same way as an ethnographer or anthropologist would do when visiting a foreign country. Kreuter et al (2003) discussed this with reference to the ideas of and ‘tailoring’ and ‘targeting’. Cultural tailoring refers to designing interventions that take account of individual patient preferences, while cultural targeting considers group members who share similar practices, values and beliefs. Kreuter (2003) et al suggested that individual differences
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between those who may have a similar culture can be understood because ‘although culture is shared, individuals within a given culture can have varying levels of certain cultural beliefs’. This point was supported by one of the nursing students in the focus groups who commented that in some African cultures involvement of an outside agency to provide care for a family member is seen as a failing. The nursing student went on to say that it was part of her remit to reassure these families who used respite services that this was an acceptable option. Although person-centered care is essential to meet patients’ individual needs, it is only successful when it is planned and delivered in partnership with the patient. Nursing students may benefit from role play and human patient simulation as a means of providing opportunities to rehearse practical skills in a non-threatening and safe environment. The ability to make
mistakes and learn from them is vital. Facilitated by staff skilled in addressing cultural issues, simulation and role play can help students focus on the practical cultural dynamics of the nurse-patient encounter. Any simulation and role play sessions should be supported by lectures and seminars that provide students with the underpinning knowledge and understanding to consider the wider socio-economic, political, and cultural contexts that affect patients’ abilities to access health care. Liaison with service user groups, faith groups and representatives of various cultural divisions, with the intention of incorporating their particular world view into structured classroom activity, is also advocated by the authors. Although this type of activity might only provide a superficial level of engagement, it serves as an introduction to the complex layers of diversity that nurses are likely to encounter in practice.
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Cambridge P, Carnaby S (Eds) (2005) Person Centred Planning and Care Management with People with Learning Disabilities. Jessica Kingsley Publishers, London. Campinha-Bacote J (2002) The process of cultural competence in the delivery of healthcare services: a model of care. Journal of Transcultural Nursing. 13, 3, 181-184. Centre on Dynamics of Ethnicity (2013) What Makes Ethnic Group Populations Grow? Age Structures and Immigration. www.ethnicity. ac.uk/census/CoDE-Age-StructureCensus-Briefing.pdf (Last accessed: February 19 2014.) Clegg A (2003) Older South Asian patient and carer perceptions of culturally sensitive care in a community hospital. Journal of Clinical Nursing. 12, 2, 283-290.
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Divi C, Koss RG, Schmaltz SP, Loeb JM (2007) Language proficiency and adverse events in US hospitals: a pilot study. International Journal for Quality in Health Care. 19, 2, 60-67. Dreher M, Macnaughton N (2002) Cultural competence in nursing: foundation or fallacy? Nursing Outlook. 50, 5, 181-186. Elo S, Kyngäs H (2008) The qualitative content analysis process. Journal of Advanced Nursing. 62, 1, 107-115. Fisher TL, Burnet DL, Huang ES, Chin MH, Cagney KA (2007) Cultural leverage: interventions using culture to narrow racial disparities in health care. Medical Care Research and Review. 64, Suppl 5, 243S-282S. Flores G (2006) Language barriers to health care in the United States. New England Journal of Medicine. 355, 3, 229-231. Hatton C (2002) People with intellectual disabilities from ethnic minority communities in the United States and the United Kingdom. International Review of Research in Mental Retardation. 25, 209-239.
Henley A, Schott J (1999) Culture, Religion and Patient Care in A Multi-Ethnic Society: A Handbook for Professionals. Age Concern Books, London. Hsieh HF, Shannon SE (2005) Three approaches to qualitative content analysis. Qualitative Health Research. 15, 9, 1277-1288. Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA (2004) Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of General Internal Medicine. 19, 2, 101-110. Kai J, Beavan J, Faull C, Dodson L, Gill P, Beighton A (2007) Professional uncertainty and disempowerment responding to ethnic diversity in health care: a qualitative study. PLoS Medicine. 4, 11, e323. Kleinman A, Benson P (2006) Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine. 3, 10, e294. Kreps GL, Kunimoto EN (1994) Effective Communication in
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Art & science research Limitations The study was devised and conducted by three white, middle class academics, which may have affected the interpretation of data. Another limitation may have been the small sample size and inclusion of participants from particular branches of nursing in the focus groups, which may affect the generalisability of the findings. Ethnic minorities were also mainly represented by patients from the Muslim community, however this reflects the demographic of the region.
Conclusion Recognising and respecting cultural diversity is essential to ensure that individual patients’ needs are met. Nursing students should receive training and education to ensure that they are able to provide care in an increasingly culturally diverse healthcare environment. Issues surrounding cultural sensitivity
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and diversity should form part of pre-registration nurse education and should be reinforced throughout the nurse’s career to ensure personal and professional development, and the delivery of culturally competent and equitable health care NS See student life page 66
IMPLICATIONS FOR PRACTICE Cultural competence is essential in an increasingly culturally diverse healthcare setting. Patient-centered care should be adopted by all healthcare professionals to ensure that individuals’ needs are recognised and met. Nursing students require preparation during pre-registration education and support while on clinical placement to deal with the challenges of providing care for people from diverse and often unfamiliar backgrounds.
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