Nurses' experiences of caring for culturally diverse patients in an acute

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Identification

if nurses' experiences if caringfor culturally diverse patients in

acute care settings contributes to transcultural nursing knowledge. This qualitative study aims to describe nurses' experiences

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diverse adult patients on medical and surqical wards in an acute care settina. These experiences identify current practice and associated issues for nurses

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ten registered nurses carinq Ior culturally diverse clients, A purposive sample was' interviewed and transcripts analysed. Il1ain findings were acquiring cultural knowledae, cammittina to ond enaaaina with culturally diverse patients. Strateqiesfor change developedfrom thesefindings focus on increasing cultural KEYWORDS

cultural diversity; nursing practice; acute care; cultural competence

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competency nurses by: implement ina aformal education proaram; developing partnerships with patients and theirJamilies to increase cultural comJort; and increasins orpotusational accommodation oj the culturally diverse with poltcy review and extension oj resources. Further research to explore issl~bilinsual nurses and to describe the experiences

Jamilies in general acute care settinss is recommended. Received 16 October 2003

JANE CIOFFI

Senior lecturer School of Nursing, Family and Community Health College of Social and Health Sciences University of Western Sydney - Hawkesbury Campus, New South Wales

BACKGROUND ith the increase in global mobility of people the patient population in acute care facilities in Australia has become more ethnically diverse. Stall" arc therefore \vorking with patients

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of culturally diverse {£tieots 7na~·t.heir

Accepted 10 May 2005

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from different cultural backgrounds to their own. Consequently, one of the challenges facing nurses is the provision of care to culturally diverse patients. This study explores nurses' experiences of caring for culturally diverse adult patients in an acute care setting. Australia is a pluralistic society with different values and traditions (Garrett & Lin, 1990j Roach, 1997). In the health care sector patients from non-English speaking backgrounds have been categorised as patients 'of culturally and linguistically diverse backgrounds'. This term is inclusive of people of indigenolls and migrant backgrounds (Roach, 1999). Further, the Australian health care sector has been identified as

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Caring for culturally diverse patients in an acute care setting

strongly Anglo-centric (Blackford & Street, 2000; Wotton, 2000) with nursing practice duminantly Anglo-Australian (Blackford & Street, 2002; Blackford & Street, 2000; Blackford et aI., 1997). Dual ethnocentrism is therefore present between nurses and patients. According to De Santis (1994) dual ethnocentrism makes the provision of care in nurse-patient encounters difficult. Such difficulties have been reported in empirical studies. International studies have shown nurses' experiences of caring for culturally diverse patients are challenging and frustrating (Adams et aI., 1992; Bernal, 1993; Kirkham, 1998; Shareski, 1992; Thobaben & Mattingly, 1993; Zwane & Poggenpoel, 2000). Nurses have expressed difficulties with cultural diverse patients (Adams et al . 1992). These difficulties have included language barriers (Bernal, 1993; Murphy & Clark, 1993), delivery of quality care (Boi, 2000; Khanyile, 1999; Zwane & Poggenpoel , 2000), the bureaucratic health care system (Bernal et aI., 1990), nurse-client relationships, dealing with relatives, personal stress and help. lessness (Murphy & Clark, 1993). From their experiences, nurses have identified factors that influenced care of culturally diverse patients as being education (Bernal & Froman, 1992; Boi, 2000), previous work experience (Pope-Davies et aI., 1994) and multicultural exposure (Bernal & Froman, 1992). To date studies in Australia addressing nurses and culturally diverse patients have focused on childbirth situations (Cioffi, 2004; Rice, 2001; Rice et aI., 1999; Nahas et aI., 1999; Rossi ter, 1998; Yelland et aI., 1998), the educational preparation of nurses (Omeri et al., 2003; Omeri, 1991), and palliative care (Diver et aI., 2003; McNamara et aI., 1997). Other studies have addressed the experiences of culturally and linguistically diverse nurses (Omeri & Atkins, 2002; Blackford & Street, 2000) and the experiences of nurses and midwives caring for nonEnglish speaking hackground families of dying children (McKinley & Blackford, 200 I). How-

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ever, little investigation has occurred exploring the exper-iences or nurses caring fur adult culturally diverse patients in general surgical and medical wards.

METHOD Approach This qualitative study describes nurses' experiences of caring for culturally diverse patients. The study was conducted in an acute care hospital with a 70% culturally and linguistically diverse patient population predominantly consisting of Arabic and Asian patients.

Ethics approval Ethics approval for this study was obtained from the human research ethics committees of two institutions, The University of Western Sydney Human Research Ethics Committee and The Western Sydney Area Health Service Human Research Ethics Committee.

Participants Ten registered nurses who met the inclusion criter ia: registered nurse; and five years or more experience working with culturally diverse patients on general surgical and medical wards, volunteered to join the study and formed the purposive sample. The criterion of five or more years of experience with the same patient population was used as Benner (1984) considered such experience is associated with proficiency. The sample size of ten participants was considered adequate as according to Kuzel (1992) five to eight can be considered to suffice for a homogeneous sample. This sample was homogeneous with respect to rich experiences of caring for culturally diverse patients. The registered nurse participants who came from medical and surgical wards had experience ranging from 5 to 25 years, with the median heing 9.5 years. Six came frorn non Anglo-centric backgrounds and only two reported that they had received formal transcultural nursing education. /

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Data collection procedure After a written consent was obtained each participant was allocated a numerical code to ensure anonymity. An interview was scheduled at a convenient time and place to ensure privacy usually a ward of rice. Prior to each interview participant characteristics (i .e., ethnicity, years of experience working with culturally diverse patients and formal education in multicultural aspects of health/nursing care) were recorded. Each interview lasted approximately one hour and was tape-recorded and transcr-ibed. Participants were asked to recall and describe their experiences of nursing culturally diverse patients. The investigator encouraged participants to talk freely about their experiences and feelings. Interviews were concluded when participants indicated that they had no more to say. Participants were asked if they were willing to be contacted when the findings of the study were available to consider their credibility in light of their experiences. Five agreed and provided their contact details.

Data analysis Transcriptions were read and reread to acquire a sense of and familiarity with data. This was followed by unitising and categorising the data according to Lincoln and Guba (1985) approach. First raw data was coded into distinct units of meaning then these were grouped into categories on the basis of likeness. The five participants who had agreed to be involved in the process of estahlishing credibility then checked these categories. In addition, bilingual health

workers confirmed the fittingness of the findings as being similar to their experiences of being involved with nurses caring for culturally diverse patients. Bilingual health care workers were considered appropriate to check fittingness as they support culturally diverse patients and their families during hospitalisation by liaising between health professionals and patients to promote cultural comfort.

FINDINGS Nurses' experiences of caring for culturally diverse patients can be described with three main categories. These categories are acquiring cultural knowledge, committing to and engaging with culturally diverse patients. Each category had subcategories (seeTable I).

Acquiring cultural knowledge Acquiring cultural knowledge was described by nurses as intrinsic to caring for culturally diverse patients. This process involved iJentifying anJ using cultural knowledge sources in the workplace. These sources were bilingual health workers, bilingual colleagues, patients, their families and support persons. Typical examples arc as follows: 'The bilingual health care workers are quite important in telling us about different cultural things.' 'There's a lot of Lebanese and Chinese nurses, They teach you a lat.' 'If I am not sure, I just say to the patient "What is the right thing for me to do?", "Can I do this?" or "Would you mind if 1 do this?" ,

TABLE 1: CATEGORIES AND SUBCATEGORIES DESCRIBING NURSES' EXPERIENCES OF CULTURALLY DIVERSE PATIENTS

Category Subcategories

Acquiring cultural knowledge

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Engaging with culturally diverse patients

• Identifying sources

• Willing to commit

• Involving family

• Using experiences

• Stereotyping patients • Individualising patients

• Being flexible • Relying on bilingual nurses

• Recognising inadequacy of education

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Committing to culturally diverse patients


• Being challenged • Facing issues

Caring for culturally diverse patients in an acute care :-ietting Usins experiences involving culturally diverse patients to build knowledge within episodes or care was considered by some nurses to be essential. The variability of these experiences was the aspect described as most valuable, for example:

I don't think it's something that you learn out of a book ... you learn by watching and absorbing. Every situation is just so different.

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with certain values, beliefs and lil"cways as shown in extract below: You actually have to ask the person. You can't assume that they're going to be the traditional Chinese or Arabic lady. It's just tlnding out wbat they believe and what they don't believe in and then you can work from there with them and individualise their care.

Engaging with culturally diverse patients

Most of the nurses recocrused their education had been inadequate regarding the knowledge and

understanding they required to care for culturally diverse patients. Only a couple of nurses had actually received this type of information during formal studies. As one nurse said:

lnvolvinc the family of the patient was described

My biggest issue is with the whole topic of education. I just feci we are not educated enough. We need to know a lot more about cultural nursing.

Committing to culturally diverse patients

by nurses as the key to engaging with culturally diverse patients. Family involvement was a major resource for providing care and making patients comfortable as examples below show: The family will tell you what the patient's needs are and you encourage the family to speak to you. You have to involve the family and sit down and talk with them To accommodate family involvementJ7exibility was identified to be necessary, for example:

II willinaness to commit to the culturally diverse and to make the effort to provide culturally congruent care was strongly expressed by some, for example:

You have to be flexible about the family corning to sec the patient and not just stick to the visiting hours. Patients can feci very isolated if they can't talk to anybody, can't understand what's being done or what's being said around them.

I continually strive to become more culturally aware ... to learn more about how to make things right.

This flexibility was also described in adapting procedures to be culturally acceptable as shown below: 'Arabic laches going to theatre don't like to expose their hair. I just give them a clean hospital towel and they're happy to swap it with their scarf.' 'Older Asian people like to be kept warm. You need to explain about going to theatre and the clothing. They arc happy as long as you keep them warm with blankets.'

Nurses described being committed to culturally diverse patients in two main ways. Some nurses worked from a stereotypical view of the patient's cultural group or from the perspective that a culturally diverse person is a person like any other person. As one nurse said: I treat all my patients the same, I just treat patients from different cultures like everyone else apart h-orn the language barrier. However, others perceived their paticnts as mdividuals and not just as members of cultural groups

With culturally diverse patients English speaking hackground nurses ift~l1 relied on the hi/insual


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Jane Cioff through the family. Some patients don't want their families to know what's going on.

nurses on the wards to engage with patients of similar cultural groups to their own. A typical comment was:

Nurses here are multicultural as well as the patients. Most of the time there is someone

who can speak their language. So it's easier for LIS and for patients and their families as well. For some nurses being in the midst of cultural diversity patients was challenging. As one nurse said:

Overall, I think it makes your job more interesting to look after people from different cultures ... makes it a bit more challenging. The challenges nurses faced involved both patients and their families. Main challenges nurses described were associated with commu-

nication, assessment, provision of holistic care and the limitations of working with inter-

preters. Typical examples of these situations arc as follows: 'We get a lot of patients here ... with strokes ... explaining that their family member might aspirate and things like that take a long time. Damage can be done in the period that it takes to get the understanding, especially with the family.' 'You're not dealing with the emotional aspects because they can't discuss them with you ... It's not holistic care. That's what's

difficult.' 'Most times, you've got an interpreter ... in that half an hour you have to go through everything, which is impossible.' Nurses Jaced many issues when engaging with the culturally diverse. Issues arose with patients, families and the health care system in which they worked. With patients, issues that arose were confidentiality and education. If I can only talk to the next of kin there's a confidentiality issue ... can't ask the patient is it okay because you are usually conversing

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With families, the issues were aggression and visiting. 'It can be quite threatening to you as a female because the men can be very very domineering and very aggressive and very very loud and they stand in your face.' ' ... doesn't matter that the rule is only four to a bed in visiting hours. I feel like that's a non-existent rule for them.' Within the health care system, the issues were organisational flexibility, medical officer commitment and types of bilingual health workers available. ' ... a little bit more lenience in the hospital system letting family members' stay longer ... We've had a few people ... stay the night. That's been a hard issue.' 'M Y problem is with the medical side of things. The consultant ... or the Senior says "You haven't got time ... let the nurse worry about it" ... It's very disheartening.' 'We have bilingual health care workers here. ( find the types are not enough to cater for the diverse patients we have in this hospital.'

DISCUSSION Within experiences with culturally diverse patients nurses sought the knowledge they needed to provide care that was oriented around a stereotypical or an individual perspective. Nurses faced a number of personal and professional issues with patients, families, visitors and other health workers. These issues are similar to those found in other studies (Adams et aI., 1992; Bernal, 1993; Bernal & Froman, 1992; Bernal et al.. 1990; Murphy & Clark, 1993). To accommodate culturally diverse patients and their families more appropriately, nurses considered that the health care system should he more Flexible, interpreters should be more accessible and a greater variety of hilin-


Caring for culturally diverse patients in an acute care setting gual health care workers should be available. As in other international studies (Adams ct al., 1992; Bernal, 1993; Shareski, 1992; Thobabcn & Mattingly, 1993), working with culturally diverse patients was found to be challenging. Nurses displayed empathy for cultural diverse patients and were on occasions excited by their culturally diverse experiences. Their attitudes to the challenge of caring for these patients showed that they were willing to learn about cultural diversity and to be flexible in order to achieve more cultural congruence. This frequently involved making the effort, as one nurse said, to 'make things right'. Descriptions of striving continuously to achieve the ability to work within the patient's cultural context were expressed by many of the nurses interviewed. Nurses showed they were engaged in a process of constantly working at becoming more culturally aware and knowledgeable in their interactions with patients and their families. They described assessing patients informally on a 'just in time' basis. This supports Omeri and Nahas (1995) ohservations that cultural assessment is poorly addressed in Australian nursing care assessment. As nurses were highly dependent on «perientiallearning in the workplace, the potential to spread inaccurate cultural information was present. According to Donnelly (2000), this can be addressed in ongoing staff development programmes that provide opportunities to discuss concerns about the care of culturally diverse patients. Such an approach to increasing competence would act to regulate learning in a nonpunitive manner. In addition, it has the potential to influence and encourage staff to develop deeper levels of commitment to giving culturally congruent care. The presence of many culturally diverse staff in the work force of this acute care setting were appreciated by English speaking background nurses. They recognised the professional worth and differing perspective of culturally diverse nurses. This docs not support the findings of

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Omeri and Atkins (2002). Culturally diverse nursing colleagues contributed to decreasing barriers and addressing issues of equity and access. This support') the view that health services need to have in place employment policies that address multicultural stair recruitment that arc appropriately matched to the patient populations, as recommended by Gorman (1995). However, this reliance on bilingual nurses by other nurses to provide culturally diverse patient" and their families of similar backgrounds with interpreting and cultural comfort raises issues. Though the intention is to support culturally di verse patient') more strongly this expectation of bilingual nurses places them in a position where they could be assuming an additional workload and role for which they have not been formally prepared. This may not be in the best interests of culturally diverse patients and bilingual nurses and can be considered to have implications for hospital administrators. Further, the Anglo-centric nature of the health care system in which bilingual nurses support and work with culturally and linguistically diverse patients has the potential for dissonance to be experienced by both patients and nurses. Tbough this study did not identify this issue other studies (e.g., Blackford & Street, 2002: McKinley & Blackford, 2001) have found this. Many nurses showed that they were ethically responsible for the care they provided. They acted as advocates by negotiating institutional barriers for family members to stay with patients identifying this enabled care to be given in a safer manner. They recognised their patient care was compromised by limited communications that impacted on their assessment, education and emotional support of patients. Some showed moral concern about respecting the confidentiality of the patient in situations of dependency on the family c.g., communications. These examples show how nurses integrated ethical pr-inciples into the care of culturally diverse patients. However, there were instances in daily practic; that suggest ethical


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aspects of culturally sensitive care need to be explored further . . vith staff'.

gies for change need to address these main issues. Recommendations arc:

Nurses recognised the value of family involvement. However, the management of family involvement was not clear. The role of the family member within the care context and the opportunity to identify health beliefs of the family were not addressed in-depth by nurses within their descriptions of their experiences. The issue of review of hospital policy regarding family access was raised indicating nurses considered the comfort of both culturally diverse patients and their families can be increased by hospital policy changes. Further, the role of family members who select to support their relatives at the bedside could be explored and developed so nurses can prepare and engage family members more appropriately to increase effectiveness of support and provide greater satisfaction.

• To develop cultural competence with a formal education program 1(-)1' nurses based on a needs analysis induding workshops to enable nurses to work through ethical and care issues, develop cultural assessment skills and build cultural l1exibility.

Some findings from other countries such as the United Kingdom and Canada have shown nurses' experiences to be similar. This suggests that findings may be transferable to other similar situations. However, further studies are required to confirm their relevance. The expertenccs described here have not included the perceptions of patients and their families. These need to be explored to understand more fully the experiences of this patient group.

CONCLUSION In conclusion, this study identified that nurses arc informally ae,!uiring the cultural knowledge they need to care for patients and that some usc stereotypical views of the patient's cultural group to give care with others using the perspective of the individual patient. These and the challenges and issues identified within encounters with patients and their families provided insight into current nursing practice. Main issues were the educational needs of nurses for cultural knowledge, challenges and difficulties in nurse patient family encounters and '....cakncsses in organisational infrastructure. Strate-

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To build evidence-based cultural care with research studies addressing areas requiring cultural knowledge identified in the workshops held as part of the educational program. • To increase the cultural comfort of culturally diverse patients and their families by working in partnership in continuous quality improvement activities using focus groups regularly to identify areas that require negotiation and change. • To develop a more culturally friendly organisation through oganisational accommodation of the culturally diverse by changing policies, for example family at bedside and improving infrastructure, for example 24-hour access to Interpreters particularly for the languages 01 recent types of immigrants to Australia and the availability of an increased range of bilingual health care worker types. Through these recommendations steps can be taken in the clinical setting that have the potential to develop transcultural nursing practice. This will enabling nurses to position themselves to provide more culturally congruent care to each patient from a diverse cultural background within a culturally friendly hospital.

Acknowledgements To the nurses who so willingly agreed to share their experiences of caring for culturally and linguistically diverse patient groups; to the Actincb Director of Nursing, Ms Jan Tweedie, whc ~ supported the study: to the hi lingual health workers, Ms Nawal Amahesh and Ms Ma) Chung for their support of the study; and to the


Caring for culturally diverse patients in an acute care setting University of Western Sydney who funded the stud), with a 200] Research Seed Grant.

Adams R, Briones E and Rentfro A (f 992) Cultural considerations: Developing a Ilursing care system for a Hispanic community. Nllrsino Clinics oj North America 27: 107-117.

Hemal H and Froman R (1992) Influences on the cultural self-efficacy of community health nurses. journal '!f7ransct/ltural Nt/nino 4: 24-31. Bernal H, Pardue K and Kramer M (t 990) Rewards and frustrations of working with ethnic minority populations: An Hispanic unit experience. Home Hcoltbcarc Nurse 8: 19-23.

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ADVANCES IN CONTEMPORARY TRANSCULTURAL NURSING Edited by John Daly & Debra Jackson, University of Western Sydney 15BN 0-9750436-1-7; xiv + 190 pages; softcover: October 2003 Now in its second printing, this special issue of Contemporary Nurse is available for adoption in 2005 health care courses. Coordinators of the following courses are invited to request an evaluation copy:

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