Learning About Difference

Ask a student entering nursing school why nurses need to use different criteria in diagnosing cyanosis in African Americans, why a Vietnamese mother might leap up in terror when a nurse touches her child’s head or why some Asians are fearful of health care providers in white uniforms. Chances are, the student will not have a clue.

But after spending a year at one of the growing number of nursing schools that offer multicultural education, they will know the answers to those questions and many more. They will have learned that African Americans’ skin turns dusky, not blue, when they’re cyanotic; that some Vietnamese mothers believe evil spirits will visit their child if strangers touch the head; and that certain Asian cultures associate white with death.

As people of diverse races, ethnicities and cultures continue to cover the U.S. like a colorful quilt, nursing schools are recognizing the importance of teaching students about diversity before they enter the workplace, where they will face patient care situations that demand cultural and linguistic sensitivity.

In health care, cultural competency means treating patients from different racial and ethnic backgrounds, as well as the elderly and indigent, in accordance with their unique cultural needs, beliefs and risk factors. Linguistic competency means being able to converse in a limited-English-speaking patient’s native tongue or having access to a qualified translator.

Cultural and linguistic competency benefits the entire health care system because it is a more holistic approach to health, educators say. And it’s desperately needed as the nation’s minority population continues to increase in the face of health risks that disproportionately affect those populations, according to Kem Louie, RN, PhD, president of the Asian American/Pacific Islander Nurses Association and associate professor in the Department of Nursing at William Paterson University in Wayne, N.J. “The devastating statistics concerning the health disparities among ethnic minority groups in America rival those of Third World countries,” she says.

Although the U.S. Office of Minority Health recently issued first-ever national standards for culturally and linguistically appropriate services (CLAS) for health care organizations and providers, no such federal guidelines exist for incorporating cultural and linguistic competency into nursing school curricula. Nevertheless, nursing schools around the country are rising to the challenge on their own and designing multicultural programs of study.

A Diversity of Approaches

Colleges of nursing vary in how they have chosen to incorporate cultural and linguistic competency into their curricula. Some schools have gone so far as to throw out their existing curricula and start afresh. Others have created separate teaching units focused exclusively on cultural competency. Still others are weaving cultural competency education throughout their traditional curricula. In addition, some schools recommend or even require students to take cultural anthropology courses and to study a second language in order to increase their cultural and linguistic competency.

This educational refocusing reflects both America’s growing cultural diversity and the expanding role of nurses at the dawn of the new millennium. Not only are today’s nurses expected to provide health care, they are also being called on to act as liaisons between the health care system and the patient. Shirlee Drayton-Hargrove, RN, PhD, co-editor/author of the book Case Studies in Multiculturalism, calls this being a cultural broker.

“[Nurses] need to have extensive knowledge of, and respect for, differences in cultures when dealing with patients,” says Drayton-Hargrove, who is director of the Family Nurse Practitioner program and an assistant professor at Widener University in Chester, Pa. “They must have awareness of subcultures—such as knowing that Latinos don’t all speak the same language and that African Americans don’t all like the same kind of foods. They also need to know what to do when cultural differences become obstacles in caring for patients.”

Widener’s undergraduate school of nursing teaches multicultural concepts by integrating them throughout the curriculum and offering students opportunities to gain practical experience working with diverse patients at local clinics. For the past eight years, the school has also assembled ethnically diverse panels to discuss cultural competency with students. The format has been highly successful, says Jane Brennan, RN, DNSc, assistant dean for undergraduate studies.

The university’s graduate nursing program takes the same approach, often calling upon its diverse student population to offer insights into their own cultures. “It’s like a little United Nations here,” says Mary Walker, RN, EdD, dean of graduate nursing. “We have students from everywhere, including a growing number from the Middle East. We sponsor International Days, where students present projects on a particular culture and its beliefs. We even have a writing center and language institute on campus to help students learn the languages of the populations they are working with.”

At the University of Utah in Salt Lake City, students in the undergraduate nursing program learn about different cultures not only in the classroom but also by working at shelters, clinics and the university’s hospital. “They come back to class wide-eyed and with a wealth of new knowledge,” reports Sue Chase-Cantarini, RN, MS, clinical instructor and coordinator of diversity affairs at the university.

They learn, for example, that Hispanics—who comprise a high percentage of the minority population in Salt Lake City—tend to consult with family members before making major medical decisions; that people from certain cultures may assume doctors and nurses know what’s wrong with them without having to ask questions; and that some Native Americans can be traumatized if a health care provider tries to remove the little bags containing essential oils that are often worn around the neck for healing. Other cultures wear jewelry they believe has healing properties, and students learn that they can tape over the jewelry prior to surgery, rather than cut it off.

To reinforce this cultural learning, instructors at the University of Utah hold “debriefing sessions” at the community clinics and other setting where the students have been working. In addition, the nursing school holds monthly seminars, sponsored by the university’s Office of Minority Affairs, in which health care workers from different ethnic groups lead classroom discussions on the challenges of providing health care to particular minority cultures.

The Community as Classroom

Perhaps the most dramatic and innovative example of teaching cultural competency in nursing school can be found at the University of Central Florida in Orlando. In 1997, the university’s nursing program scrapped its traditional undergraduate curriculum and replaced it with one centered almost entirely on clinical experience in the community.

“We’re breaking down the walls,” says Ermalynn Kiehl, ARNP, PhD, who coordinates the flow of nursing students into community clinics. “Not many schools are making such drastic changes.”

Students spend the entirety of their first semester at senior centers, schools and clinics, doing health screenings and assessing the needs of the local population, which is 40% minority—primarily African American, Hispanic and Haitian. Second-semester students spend half of their time working in the community and the other half coordinating the long-term care of patients they worked with in their first semester.

To maintain continuity of care, clinical work in the community is also emphasized in the student’s third semester. “You can’t jump in and out of the community just to satisfy the needs of the curriculum,” Kiehl explains. “It’s not fair to the people being served.”

“Our students love the new curriculum,” says Elizabeth Stullenbarger, RN, DSN, director of nursing and professor at the university. “Many of them come from the same ethnic backgrounds as their patients, so they speak the same language.” In cases where language barriers are a problem, she adds, the students are so diverse that they can translate for each other.

When they first start working in the community, Stullenbarger continues, students sometimes feel they aren’t learning traditional nursing skills. “But they soon realize that they are learning the basics. They learn how to do blood pressure checks and give injections, as well as how to perform other procedures.” Most important of all, they are learning how to provide culturally competent health care to a wide variety of patients.

Creating Culturally Aware Nurses

At South Carolina State University (SCSU) in Orangeburg, S.C., cultural competency training is a strong component of classroom instruction, says Ruth Johnson, RN, EdD, FAAN, professor and chair of the Department of Nursing. Because most of the students at South Carolina State are African American, she says, the topic of culture “is a given.” Even before the expression “cultural competency” came into being, nursing students at SCSU were learning to communicate with patients who speak Gullah, a Creole language now spoken primarily in nearby Charleston by descendants of African slaves.

Although still predominantly African American, SCSU has recently begun to attract students from Africa, Iran, Afghanistan and other countries. Orangeburg itself has seen an influx of Japanese, Koreans and Central and South Americans, which has made it even more crucial for students to learn about different cultures, Johnson notes.

Up north in Chicago, always a melting pot for different races and ethnicities, adding a multicultural component to courses in nursing at the University of Illinois at Chicago was the obvious thing to do, says Eva D. Smith, RN, PhD, associate professor in the university’s College of Nursing, where students from around the world learn about a variety of cultures in seminars, workshops and independent study programs.

Cultural competency, Smith stresses, must begin with an understanding that “culture” is defined not only in racial and ethnic terms, but also by religious, socioeconomic and geographic differences. As part of their multicultural training, nursing students at the University of Illinois choose someone from a different cultural background than their own—perhaps a fellow student or next door neighbor—and follow that person through the semester. They study what the person eats, his or her health practices and the habits dictated by the subject’s culture. This in-depth approach, Smith says, helps students appreciate and value cultural differences.

While educators say that most nursing students are eager to share their own cultures with their classmates, Cantarini-Chase has found that some students worry about being treated as token minorities and resent being called on to answer questions pertaining to their ethnic group. “They take it as an insult,” she cautions, “so we need to be careful.” Still other students may reject the whole differentiated-culture approach, demanding “Can’t you just call us all human beings?”

But overall, such views seem to be the exception, not the rule. “Students are very accepting of cultural competency here,” Smith says of University of Illinois nursing students. “At the end of each semester, we hold a potluck luncheon and students and faculty bring their favorite ethnic dish. Forty percent of our students are Asian, African American or Hispanic, with a smattering of Russian and Yugoslavian students. We talk about cultural pluralism and each student brings something valuable to the discussion.

“When we first ask students how they identify themselves,” she adds, “most say, ‘I’m American.’ But four years later, they say, ‘I’m Asian,’ or ‘I’m Mexican,’ or whatever their culture is. Students need to come to terms with their own cultural identities before they can really understand and appreciate other cultures.”

Johnson notes that some students may initially be nervous about working with people who are culturally different from them, whether the difference involves race, nationality, generation or socio-economic status. “But we quickly start seeing that the students are responding favorably to their exposure to other cultures,” she says. “Some have said, ‘Before this, I would never have taken time to talk with elderly people.’”

Faculty Involvement is Key

Nursing schools agree that cultural competency programs work best when the faculty acknowledge and support the need for such an approach—something that can take a bit of persuasion. “Faculty members have a difficult time giving up educational content they know well and are comfortable with,” Kem Louie says.

One way to foster faculty enthusiasm and cooperation is to involve them in formulating the new curriculum. At SCSU, the predominantly African-American faculty “owned the cultural competency curriculum,” Johnson says. “They helped design the program, using their own experiences—personal and professional.”

The same is true at Widener University, Walker relates. “It’s a work in progress. For example, if faculty members want to update the curriculum to reflect new research or emerging trends, they can. There isn’t a lot of red tape.”

Like most American colleges and universities, Widener does not have many minority faculty members. While the University of Illinois’ Smith believes “you don’t need to be a minority to teach cultural competency,” all of the educators interviewed for this article say they would welcome a more racially and ethnically diverse faculty.

Louie feels it’s crucial that both Caucasian and minority faculty members work together to develop their school’s cultural competency program. “In my experience,” she says, “it has been the minority faculty who have predominated in introducing cultural and linguistic competency into the curricula. We need to send the message that majority groups must also be active in addressing cultural competency.”