Because immigrants from Asian countries with large Buddhist populations are a rapidly growing minority group in the U.S., it’s important for nurses to understand Buddhist patients’ beliefs about health, illness and food.
The love of nature and maximum enjoyment of what nature provides us is necessary in order to live a truly natural life. This is the main belief in many Asian cultures, such as those of China, Japan, Taiwan, Korea, Tibet, Sri Lanka, Thailand, India and the Philippines. While Christianity is the dominant religion in many of these countries, there are also significant numbers of Buddhists, along with Muslims, Hindus and atheists.
In the Buddhist faith, life revolves around nature with its two opposing energy systems, known in Chinese philosophy as yin and yang energy. Examples of these opposing energy forces, which are cyclical, include heat/cold, light/darkness, good/evil and sickness/health. Although a simple illness, such as a cold or flu, may be considered an imbalance of yin and yang energy, many Buddhists-though not all-believe that the best way to live a healthy life is to be a vegetarian.
The Buddhist tradition of vegetarianism has gained a great deal of popularity around the globe, as both a diet and a way of life. In the United States alone, there are about 20 million vegetarians. At the same time, in certain Asian cultures there has been a strong movement away from the traditional strict vegetarian diet as a result of these countries’ exposure to Islam and Christianity.
Part of being a culturally competent health care professional is being careful not to make blanket generalizations about patients from unfamiliar cultures-such as assuming that if a patient is an immigrant from an Asian country, he must be a Buddhist. Even if it is known for a fact that the patient’s religion is Buddhism, this does not necessarily mean that he or she strictly follows all Buddhist religious practices to the letter. It is vitally important for nurses to initiate dialogue with patients and their families in order to determine what, if any, cultural/religious needs and dietary restrictions must be accommodated to ensure the best possible healing process for the patient.
Understanding Buddhist Beliefs
The Buddha was born in what is now Nepal and founded Buddhism in India during the sixth century B.C. After Buddha’s death, his followers considered him a divine entity with the ability to lead them to Heaven.
This is a faith of supreme optimism that teaches self-control as a means to search for true happiness. Buddhists practice yoga and meditation as a means to reach spiritual emancipation or true liberation. Through mastering self-control, a Buddhist can reach full potential toward a journey of self-improvement during this life in order to achieve reincarnation, or rebirth after life. The rebirth process requires a desirable state of freedom or purity from primitive human desires and wishes.
The Buddhist code of morality is set forth in the Five Moral Precepts, which are:
1. Do not kill or harm living things.
2. Do not steal.
3. Do not engage in sexual misconduct.
4. Do not lie.
5. Do not consume intoxicants such as alcohol, tobacco or mind-altering drugs.
Buddhists believe that being careful in selecting the food one eats correlates with the amount of light in one’s body and the degree of power necessary to climb up the spiritual ladder-i.e., to reach the desirable state of relaxation and of being sincere to oneself and others. By following this path, one’s soul reaches harmony, the desirable spiritual status and/or the power of virtue necessary to attain the reincarnation process.
Buddhist Dietary Practices
In the teachings of Buddha, this concept of making the right food choices for spiritual enlightenment is exemplified by the “Five Contemplations While Eating.” Essentially, this means that Buddhists are exercising a special force related to “stopping and thinking” about the food they are eating.
(Interestingly, it is believed that the Buddha himself actually died from food poisoning.) A Buddhist asks himself these five basic but essential questions:
1. What food is this? = The origin of the food and how it reached me.
2. Where does it come from? = The amount of work necessary to grow the food, prepare it, cook it and bring it to the table.
3. Why am I eating it? = Do I deserve this food or not? Am I worthy of it?
4. When should I eat and benefit from this food? = Food is a necessity and a healing agent because I am subjected to illness without food.
5. How should I eat it? = Food is only received and eaten for the purpose of realizing the proper way to reach enlightenment.
A Buddhist GlossaryVegetarianism: A diet that includes no meat. In the Buddhist religion, eating a vegetarian diet is a natural and logical ramification of the moral precept against the taking of life. Veganism: A philosophy of life that should be thought of as entirely separate from vegetarianism. It is concerned with an entire lifestyle rather than just a dietary regime. Veganism prohibits not only the eating of animals, animal products and their derivatives-including milk, cheese and honey-but also the use of animal furs, leathers, skins, etc. Vegans believe these products-and even their by-products-must be avoided at both the physical and mental levels to ensure true liberation that facilitates the attaining of enlightenment.Ahimsa: The act of not killing or harming. It refers to the compassionate, non-violent treatment of living things and the acknowledgment of all sentient creatures’ right to live and be reborn. Practicing ahimsa will keep the Buddhist on the right spiritual path and enforces “a better life and better health.”Karma: A sort of spiritual bank account that is accumu-lated through one’s actions in life. Good karma occurs for those who follow Buddhism’s moral precepts; it will lead to being reborn as a higher being, such as a god or wealthy human. Bad karma, which can result from forbidden acts such as killing living things, can cause one to be reborn as a lesser being, such as an animal, insect or demon. Once you pay off your karmic “debts,” you can be reborn as human.
Buddhists who are strict adherents to their faith depend not only on these Five Contemplations but also on the Five Moral Precepts to determine which foods are appropriate to consume and which are considered forbidden. In general, Buddhism prohibits the eating of any and all meat, because (1) the killing of animals violates the First Moral Precept and (2) meat is considered an intoxicant to the body, which violates the Fifth Moral Precept.
According to the Fifth Precept, consuming any type of intoxicants will reflect negatively on a Buddhist’s life and afterlife in the following ways:
o Effects on Self: It will distort and cloud one’s samadhi-i.e, it will hinder one’s judgment and decrease proper concentration necessary for meditation, which is the path to enlightenment.
o Effects on Others: It will increase one’s susceptibility to commit crimes and do wrong to others, which means loss of the desirable self-control.
o Religious/Spiritual Effects: It can cause bad karma (see Glossary) that harms other sentient beings and later on will haunt the original being.
Buddhists believe that whoever lives only for pleasure loses his soul’s harmony and the power of virtue. According to the “no killing” precept, whoever kills animals or eats meat will lose the “purity of both body and mind”-i.e., one gets all mixed up with the meat one eats and loses purity, clarity and the power of self-control. Buddhists also believe that causing the suffering of living creatures just to satisfy our taste buds is not a justifiable reason to eat meat. In Buddhists’ eyes, hunger is the minimal expression of compassion that can be offered and becoming a vegetarian is a choice-i.e., choosing not to kill animals (out of kindness) and not to eat them (out of compassion).
In addition to the physical suffering of animals, Buddhists believe that eating meat also causes another type of suffering: bad karma. Killing a sentient being forces it to begin a painful process of rebirth. Since Buddhists believe it is possible for animals to attain enlightenment, killing them deprives them of that chance. Eating a vegetarian diet helps ensure that the cycle of karmic retribution will be purified:
If you don’t eat animals, they won’t eat you. If you don’t kill them, they won’t kill you.
Other foods that may fall into the “forbidden” category include “the Five Pungent Spices.” This refers to onions, scallions, chives, garlic, etc. Traditionally, Buddhists have believed that a person who eats these foods will suffer the following ill effects:
His blood and flesh will be rejected by the gods, and the heavens will distance themselves far from him.
His breath is always foul; therefore, all gods and saints will reject him.
If eaten cooked, these foods will arouse lust and cause explosive temper.
If eaten raw, they will increase one’s anger and cause bad body odor that will not please the gods but will stimulate interested “hungry ghosts” who will hover around and kiss one’s lips. Being near ghosts is believed to hinder one’s enlightenment.
Today, however, many vegetarians around the world, including some Buddhists, may eat the Five Pungent Spices without reservation. For Buddhists, this depends on such factors as the person’s degree of adherence to their faith, whether they are practicing Buddhism along with other faiths, and their geographic location.
Health Benefits of the Buddhist Diet
Examples of permitted foods that are staples of the traditional Buddhist diet in many Asian cultures include:
1. Boiled or stir-fried noodles flavored with aromatic spices. Raw or cooked vegetables, seaweed and home-prepared dried food items can also be added.
2. Rice, which can be cooked and flavored in many different ways-e.g., salty, sweet, neutral, sticky, colored or mixed with vegetables.
3. Soy sauce is an essential tasty ingredient that is added to almost every dish, in much the same way as Americans flavor many of their foods with butter and/or salt.
4. Sesame oil is also used heavily in preparing food. Unlike soy sauce, it contains no sodium.
5. Buddhists who are not strict vegetarians will eat fish on an almost daily basis and/or will add it to many of their meals.
6. Herbal tea is a popular and healing drink that originates from various types of tea plants.
For centuries Buddhists have believed that when meat is eaten it accumulates in the body, turning into harmful toxins. Today, modern medicine seems to be proving them right. A number of recent scientific studies have discovered a high incidence of cancer within populations that consume large amounts of meat. Other negative health consequences that have been linked with eating meat include arterial sclerosis, heart disease, high blood pressure, encephalitis, stroke, gallstones and cirrhosis of the liver. All of these conditions are directly related to consuming fat and cholesterol.
According to the Encyclopaedia Britannica, meat does in fact contain wastes and toxins, such as uric acid, that have negative effects on blood and body tissues. In contrast, vegetable proteins obtained from nuts, beans and legumes are decidedly healthier and safer. Furthermore, meat, meat products, poultry and seafood all spoil easily within a few hours, but most vegetables stay fresh for several days. Although beans may become rancid relatively quickly, the deterioration is much easier to detect and recognize compared to spoilage in meat, which may not always be detectable by smell or taste.
Cultural Competence Tips for Nurses
When caring for patients who are followers of the Buddhist religion, nurses need to understand that the patient’s main goal is to bring back the body’s yin/yang equilibrium that was disrupted because of illness. It is helpful to first discuss the patient’s illness and care plan in relation to this concept before volunteering a medical or patho-physiological explanation. Because of the supreme importance of nature in Buddhists’ lives, a culturally sensitive medical team will want to prescribe both herbal medicine and pharmaceutical medications, if appropriate. Remember, in these patients’ eyes the goal is not curing but rather maintaining peace of body and mind that will ensure the rebirth process after death.
In terms of dietary assessments, the first step is obviously to find out whether the patient is a vegetarian, how strict or liberal he/she is in following the traditional vegetarian diet and whether there are any other dietary restrictions the patient must observe. The risk of vitamin B12 deficiency among pure vegetarians can be managed by increasing their daily intake of the different types of vegetable proteins.
Buddhist patients staying in a hospital that only serves American-style food may appreciate being provided with a bottle of soy sauce that they can keep in their room to flavor their meals in the way they are accustomed to. The rule of thumb is: When in doubt, ask the patient what he or she would prefer. Be sure to check the labels on different soy sauce products for their sodium content, which can range from 300 grams to as much as 1,080 grams.
Gihan ElGindy, MSN, RN, is an educator and independent consultant on health, nursing, cultural competence, education and business entrepreneurship issues. She is the executive director of the Transcultural Education Center (TEC) in McLean, Virginia. For more information about TEC, visit www.tecenter.org.
The practice of meditation is used in many cultures to reduce stress and anxiety and to maintain optimal psychological and spiritual well-being. Meditation has been extensively studied as a treatment for not only improving cardiovascular health, but also anxiety disorders as well. Since burnout and anxiety are common conditions plaguing health care professionals around the world, nurses must understand the healing power that meditation has in assisting them maintain physical, mental, and emotional balance. By learning how to incorporate the complementary practice of meditation and mindfulness into their lives, nurses have the ability to learn advantageous coping skills to handle potentially stressful situations.
The Art of Meditation and Mindfulness
The ancient art of meditation and mindfulness was derived from ancient Buddhist and yoga practices around 1500 BCE. Mindfulness refers to a process that guides individuals in maintaining a mental state characterized by nonjudgmental awareness of the present moment. The basic premise underlying meditation and mindfulness centers on how experiencing the present moment nonjudgmentally and openly can effectively counter the effects of stressors, because excessive orientation toward the past or future can be related to feelings of depression and anxiety. It is further believed that by teaching nurses to respond to stressful situations more reflectively rather than reflexively, meditation can effectively counter experiential avoidance strategies, which are attempts to alter the intensity or frequency of unwanted internal experiences from the outside realm.
Mindfulness-Based Stress Reduction
Due to the incredible health benefits that meditation and mindfulness possesses, Kabat-Zinn conceptualized a highly effective and integrative approach for reducing the physical, emotional, and mental consequences of chronic stress and anxiety. Mindfulness-based stress reduction (MBSR) is an innovative therapy that blends various elements of different Eastern meditation practices with western psychology. MBSR is a formal eight-week evidence-based program that challenges the patient to cultivate a greater awareness of the unity of the mind and body as well as the unconscious thoughts, feelings, and behaviors that can influence their overall health. During MBSR therapy, the individual learns various coping skills and techniques aimed to reduce the physiological effects of stress, pain, or illness by participating in experiential exploration of stress and distress to develop less emotional reactivity.
Since the mind is known to play an influential role in stress and stress-related disorders, MBSR has been shown to positively affect a range of autonomic physiological processes, such as lowering blood pressure and reducing parasympathetic arousal and emotional reactivity. In addition to mindfulness practices, MBSR also utilizes yoga to help promote wholesome physical activity and prevent unhealthy complications associated with living a sedentary lifestyle.
Due to the many health benefits it possesses, MBSR has been shown to relieve pain and improve psychological well-being across the health care spectrum. Because of this realization, nurses should make a more concerted effort in incorporating mindfulness meditation practices into their daily lives to not only improve their own stress reactivity, but also imbue resiliency to stressful and arduous psychological challenges associated with working in the health care setting.
Coping with the potential loss of one’s child is a devastating experience, and cultural influences may further hinder the opportunity for the integration of pediatric palliative care. A 2008 survey published in Pediatrics reported that over 40% of health care providers identified cultural differences as a frequently occurring barrier to adequate pediatric palliative care. Children with life-limiting illnesses deserve a cultural reassessment of how we care for them when the goal of care has changed from curative to palliative.
The concept of cultural competence and its necessity in the treatment of diverse patients
has come to the surface of the medical community within the last decade. Health care providers must demonstrate knowledge and respect of individual as well as group value systems to become effective in providing care to this population. In response to the United States becoming increasingly multicultural, the Institute of Medicine has published two reports that support the need for cross-cultural training: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare and The Future of Nursing: Leading Change, Advancing Health.
According to the American Academy of Pediatrics, the goals of pediatric palliative care are the same goals as adult palliative care, which includes providing support and care for pain, psychological and social stress, physical symptom management, and spirituality. However, the difference regarding pediatric palliative care is that the focus is specifically aimed at serving the needs of the child as well as the family. A challenge specific to pediatric palliative services is that end-of-life care for a child seems inherently unnatural in the mind of many parents and family members who often struggle to accept that nothing more can be done for a child.
The literature frequently references the underutilization of palliative care services among ethnic minorities, including African American, Latino, Native American, Russian, and Vietnamese cultures. The following attributes have been identified in the literature as a source of underutilization: a lack of the family’s familiarity with hospice and palliative care services; language barriers; religious differences; difficulties in accessing insurance; distrust of the health care services; and discomfort with introducing additional health care with professionals not of one’s ethnic or cultural background.
In 2002, the Initiative for Pediatric Palliative Care (IPPC) published recommendations for providing culturally sensitive end-of-life care that utilizes a framework that includes: improving pediatric palliative care by maximizing family involvement; understanding the influence of religion in pediatric palliative care; and understanding how culture influences lifestyle and shapes the universal experiences of illness, pain, and death across the cultural barriers. An appreciation for cultural norms and customs is critical if we are to be successful in supporting the child and the family in reducing suffering and providing comfort and support.
Cultural Influence in Decision Making As a result of the IPPC recommendations, several organizations have created reference materials and guidelines for clinicians to use. For instance, the University Of California School Of Nursing published Culture and Clinical Care, which discusses culturally competent care across 35 cultural groups. The University of Washington Medical Center (UWMC) offers Culture Clues fact sheets of useful tips when communicating with Latino, Russian, and Vietnamese cultures (among others). The journal Palliative and Supportive Care published an article in 2013 comparing cultural and religious considerations in pediatric palliative care. These resources cited the following cultural differences in end-of-life decision making:
African American • Many aspects of African American culture today reflect the culture of the general U.S. population.
• The structure in African American families is often nuclear and extended with nonrelated “family” members.
• The family may be matriarchal, although father or mother may take on the decision-making role.
Latino • Family involvement is very important in the Latino culture.
• The family-centered model of decision making is highly valued and may be more important than patient autonomy.
• The mother is typically regarded as the primary caregiver and often will make the decisions regarding care; however, when possible, Latino women will seek permission of the child’s father before a decision is made regarding continuing or discontinuing treatment.
• Often, when language becomes a barrier, the normative hierarchical family structure is waived and deferred to the family spokesperson who speaks the best English.
Native American • Given the importance of family in the Native American culture, the entire family may be included when making decisions and signing documents.
• Native Americans may also desire that information is shared with community leaders so that they can assist in the decision-making process for the child.
Russian • Health care information is shared with family members.
• The entire family makes decisions along with the patient, and the person closest to the patient often has the most influence.
• The doctor—not the nurse—is expected to share the patient’s prognosis with the patient and family, as he or she is typically regarded as the ultimate authority in all medical matters.
Vietnamese • Family has a central role.
• Decisions are often the responsibility of the eldest male, yet older women may also have significant influence.
• Traditionally, the eldest male is the family spokesman; however, the person with the best English often assumes this role.
• Removal of life support may require extensive family discussion, which places the responsibility for the decision on the entire family instead of one individual.
Importance of Faith and Religious Traditions Faith and religious traditions are held of great importance in the majority of cultures; however, it is important to note that cultural traditions are dynamic and cannot be generalized to all families. While guidelines may offer an approach to religious considerations pertaining to end-of-life care, the provider must perform an individual assessment of the family as to their beliefs and practices. The UWMC’s tip sheets and the 2013 study in Palliative and Supportive Care offer a glimpse of the cultural differences in religious traditions during end-of-life care:
African American • Death rituals for African Americans vary widely, related to the diversity in religious affiliations, geographic region, education, and economics.
• Emotional expression varies; you are likely to see a mix ranging from public displays of crying and wailing to silent and stoic behavior.
• Death is not viewed as a formal break with life, given the belief that the spirit/soul continues and may be able to interact from the next plane of existence.
• Bereaved African Americans are more likely to seek help from clergy than from health care professionals.
• Depending on their specific cultural beliefs, African Americans might involve a healer or “root worker” whose role is important in orchestrating the natural, spiritual, and relational aspects of life.
• African Americans often rely on the health care team for help with cleaning and preparation of the body.
• African Americans may refuse to stop life-prolonging treatments because of belief in divine rescue.
Latino • Prayer and ritual may be a part of the end-of-life process for the patient and family members.
• Latino families may request that they keep candles burning 24 hours a day as a way of sustaining worship. Since candles are not permissible in hospital settings, the suggestion of using electric candles is often viewed as an appreciated gesture of respecting one’s beliefs.
• The patient and the family may wish to display pictures of saints, as saints have specialized as well as general meanings for Catholics.
• Some Latino families may want to honor their deceased relative by cleansing the body.
• The last rites are often important for Latinos who are Catholic when a person is close to death. If your patient is Catholic, ask about their preference and plans for this ritual.
• Latinos often demonstrate wailing and strong emotions at the time of death, which may be considered a sign of respect.
Native American • Death rituals among the Native American tribes vary widely because they all have different religious and spiritual beliefs. It is important to assess the religious practice of the individual and follow accordingly.
• Native Americans may wish to seek traditional healers for help in restoring harmony of life.
• Herbal remedies may be used in healing ceremonies.
• The medicine man or spiritual leader leads the ritual.
• The circle is symbolic in the ritual, as in the circle of life; therefore, the family and relatives may form a circle around the patient’s bed.
• Native Americans follow the belief that the spirit of the person never dies.
• Silence is highly valued.
• Native Americans may be hesitant to sign advanced directives or other end-of-life documents because of general mistrust related to past misuse of written treaties and documents with the U.S. government.
Russian • Russians may practice different denominations. Depending on the denomination, the family may desire to have a pastor, priest, or rabbi present at the moment of death.
• The family plays a major role in supporting the sick. Usually, there is a family member present at the bedside to attend to the patient at all times.
• Russians who practice their religion may consider prayer an important and powerful healing tool.
• In the Russian culture, relatives and friends are all expected to visit the patient. They frequently bring food and may include gifts for the clinicians as a sign of respect and thanks.
• Wailing and other displays of grief may not be demonstrated as they may be reserved primarily for expression in the home (as opposed to public display).
• Often, the family may have some specific practices for washing the body after the death. It is important to ask about preferences and try to accommodate.
Vietnamese • It is important to note that there are a variety of Vietnamese cultures and religious practices. Most Vietnamese are Buddhist; however, other religious preferences include Catholic, Evangelical Protestant, and Chinese Confucianism.
• Vietnamese who practice the Buddhist faith may call a monk to give blessings. Buddhist patients and family may chant and create an altar for prayer. Vietnamese who are Catholic may ask for a priest for last rites.
• In the Vietnamese culture, white is considered the color for mourning.
• The expression of grief varies in the Vietnamese culture. Families may express grief with either a stoic response or with crying and weeping.
• Upon death, organ transplant and/or autopsies may be accepted by the Vietnamese family with very careful explanation.
• The bereavement process of the Vietnamese culture has an extremely positive impact on family health. There is intensive and extensive community involvement with frequent visits from family and friends when death first occurs and then visits are slowly weaned off over a 2- to 3-year period.
Today’s multicultural society presents health care providers with unique challenges for providing cultural care and competence to the pediatric palliative care population. This article attempts to provide insight to but a few of the cultures that we may come across in our practice. Every person is unique, and clinicians who understand their patients’ cultural values, beliefs, and practices are more likely to have positive interactions with their patients and provide culturally acceptable care.
In nursing school, we were often told by our instructors to “treat the patient as you would want to be treated.” When it comes to treating patients with a different cultural background, this mantra should translate to “treat your patients as they want to be treated instead of how you would want to be treated.”
Karen J. Smith, MSN, CRNP, NP-C, is a doctoral nursing student at Wilkes University in Wilkes-Barre, Pennsylvania. Her background includes hospice and palliative care, and she has written health-related articles for West End Happenings.
By providing health education and wellness promotion in religious communities of color, minority nurses of all faiths can make a powerful difference in eliminating health disparities.
Not that long ago, nurses who answered a calling to promote physical and spiritual health in their places of worship were known as parish nurses or congregational health nurses. But in today’s unprecedentedly multicultural America, where many of the faithful are just as likely to attend a Muslim mosque or Hindu temple as a church or synagogue, this specialty area of nursing has acquired a new, more all-embracing name: faith community nursing.
“When what we do was first recognized by the American Nurses Association [ANA] as a specialty practice in the late 1990s, it was under the title ‘parish nursing,’” says Nancy Rago Durbin, RN, MS, FCN, interim director for faith community nursing for the Health Ministries Association (HMA), a professional association for faith community nurses (FCNs). But by 2005, when Durbin was part of a team working with ANA to update the specialty’s Scope and Standards of Practice, the limitations of that name had become glaringly obvious.
“One of the ANA leaders said: ‘Do you have to be Christian to claim this specialty?’” recalls Durbin, who is also director of Advocate Parish Nurse Ministry and the Parish Nurse Support Network for Advocate Health Care in the Chicago area. “When I said, ‘No, this is by no means an exclusive specialty, any nurse from any faith is welcome to practice,’ she said: ‘Well, your name doesn’t seem to include that.’ And she was right!”
Of course, the term “parish nurse” is still alive and well. It’s widely used to denote FCNs who work to improve health in specifically Christian settings. But professional organizations like HMA and the International Parish Nurse Resource Center (IPNRC), a ministry of the Church Health Center, now recognize that church-based nursing is one thread in a much bigger tapestry that encompasses many different faith traditions. In fact, the Church Health Center, despite its name, teaches FCN training courses to nurses of all faiths all over the world.
When and how did traditional parish nursing evolve into this broader, more culturally inclusive specialty? “I’ve always known it to be all-inclusive,” says Maureen Daniels, RN, MN, FCN, an IPNRC faith community nurse specialist. “I think it’s just the organic nature of it that’s helped it grow into more of these other faith settings. One of the things that’s so beneficial about this model is that it’s meant to be adapted to the community and to where the needs are.”
Different Faiths, Same Roles
No matter whether the faith they practice is Baptist, Buddhist, or Baha’i, minority nurses need to be involved in addressing the health and wellness concerns of their own faith communities. Even though most FCNs do this work on a volunteer basis while also holding regular nursing jobs, they can make a tremendous difference in improving health outcomes and reducing health disparities in communities of color—especially those that are economically disadvantaged and/or medically underserved.
“[Places of worship] can be a very important resource for promoting health, because they reach so many people on a regular basis,” explains Ann Littleton, a congregational health advocate at Sacred Heart Catholic Church in Greenville, Mississippi, which serves a predominantly African American congregation plus a smaller Hispanic congregation. “At our church, we probably have more people from the community gathered together in one place every weekend than anywhere else. We can pass out information about cancer, heart disease, stroke, and diabetes just like we pass out the Sunday bulletin.”
The roles FCNs perform are remarkably similar from faith to faith. The Canadian Association for Parish Nursing Ministry organizes those functions into this easy-to-remember acronym:
H – Health advisor
E – Educator on health issues
A – Advocate and resource person
L – Liaison to faith and community resources
T – Teacher of volunteers and developer of support groups
H – Healer of body, mind, spirit, and community
For example, Ameena Hassan, RN, a Muslim nurse who works in the ICU at Las Colinas Medical Center in Irving, Texas, has been providing faith community nursing services at her mosque, the Islamic Center of Irving, since 2009. It’s a large mosque, serving approximately 500 families in the Dallas area.
“We do health education classes here every month,” says Hassan, coordinator of the mosque’s Health Advisory Committee. “We do blood pressure screenings and cholesterol screenings. We do mammograms every year, usually in April. During flu season, we do flu shots.”
The mosque also holds an annual health fair. At last year’s event—attended by almost 200 community members—local physicians, nurses, and dentists provided 100 cholesterol and diabetes screenings, 33 bone density screenings, 67 dental exams, and 42 vision exams. In addition, they gave 90 attendees nutrition advice and distributed 100 bicycle safety helmets to children.
At New Horizon Church International in Jackson, Mississippi, “cardiovascular disease is the number one health problem among my congregation, so we do lots of CVD screenings, education, and referrals,” says Ella Garner Jackson, RN, CHN, leader of the church’s Health and Wellness Ministry. Jackson and her team also provide a full calendar of other disease prevention programs, including exercise classes, kidney disease screenings, and HIV/AIDS education. On the advocacy front, the ministry helps increase access to health care for low-income church members by connecting them with community resources that provide affordable prescriptions.
Because Mississippi has some of the highest levels of poverty and African American health disparities in the nation—including disproportionately high morbidity and mortality rates from cancer, diabetes, and other chronic diseases—Jackson is especially focused on the FCN’s volunteer training role. In 2005, Jackson, who is also a cardiac case manager at Mississippi Baptist Medical Center, founded the Abundant Living Community Organization (ALCO), a nonprofit organization that has taught nearly 160 nurses and non-nurse volunteers to lead health ministries in African American churches throughout the state.
Same Roles, Different Needs
How faith community nurses carry out these roles is driven by the unique needs of the communities in which they serve. In some faith settings, for instance, FCNs must tailor their health promotion activities to accommodate specific religious requirements.
“In Islam, we don’t mix men and women together in the mosque,” says Hassan. “If we’re doing something like screenings or flu shots, we have to have it in two separate places for men and women. And the women’s space has to be covered, because they don’t want to [expose their bodies] in front of others.”
But in many minority faith communities, the biggest challenges for FCNs are more likely to revolve around cultural and socioeconomic needs than belief-based ones.
“Here in the Chicago metro area, Advocate’s parish nursing program includes two Latino congregations and two African American congregations,” says Durbin. “Our nurses who work with those communities are very focused on the needs of people who are disenfranchised, undocumented, and struggling with access to care. Some of our nurses are dealing with the problem of food deserts, and they’re trying to work with the communities to create sustainable vegetable gardens and increase access to quality foods.”
Littleton, a retired English teacher who became a church health advocate after taking the ALCO training in 2010, emphasizes that “in our Hispanic health ministry, we don’t ask about immigration status. If anybody comes to us in need of our services or a referral, we try to make them feel as comfortable with us as possible. It’s important for them to feel that we’re not going to pry into their status; we’re just providing health services that they need.”
One of the most empowering ways minority FCNs can lead their faith communities down the path to healthier living is by breaking down cultural barriers that exacerbate health inequities and impede access to care.
“In some African American communities, there is still enormous distrust of the health care system,” Durbin notes. “A black faith community nurse can become the entry point for many people to develop that trusting relationship. Someone may say, ‘I went to the public health clinic down the street and they were mean to me. So I’m not going back.’ And the nurse will say, ‘Well, how about if I go with you? Because that’s where you need to be to get your meds refilled.’ Then the nurse can physically take that person back to the clinic and help them [build a better relationship with those providers].”
Durbin also notes, “In our Latino communities, men’s health is a big issue. Many of the guys have traditional machismo cultural values, so they don’t take care of their health. And traditionally, it’s the women and the older men who are the churchgoers, but not the younger guys. Latino faith community nurses who know the culture can figure out creative ways to engage that core group of men, such as providing them with health information through the people who love these men and who do go to church.”
Enlisting the aid of lay community health promoters can also help FCNs connect with hard-to-reach populations. Daniels cites the example of a group of parish nurses in Portland, Oregon, who are partnering with local promotores to extend their health ministry outreach deeper into the Hispanic community. “Because the promotores had such good relationships with the people, and people trusted them so much, they were able to get many more community members to come to health events the nurses had organized than the nurses would have gotten by themselves,” she says.
Bridging Cultural Differences
Even if a nurse doesn’t share the same religious, ethnic, or cultural background as the faith community he or she works with, collaborating with leaders within the community can be an effective way to bridge those gaps. For example, the Faith Community Health Ministry (FCHM) program at Carolinas HealthCare System in Charlotte, North Carolina, uses a model that makes it possible for the hospital system to meet the needs of virtually any belief community.
“We form partnerships with faith communities through either a faith community nurse or a faith community health promoter,” explains Sheila Robinson, BSN, RN, the program’s health ministry coordinator for Mecklenburg County. “My role is to help each one of those individual communities promote health and wellness within their own particular faith. I provide the clinical guidance and oversight to the nurses and the health promoters.”
This approach enables Robinson, an African American Christian nurse, to work with such diverse faith communities as the Hindu Center of Charlotte, a temple that serves about 2,000 families. Her health promoter partner is Chidaabha Vyas, vice president of the Hindu Center’s executive committee. When they first teamed up in 2012, one of their key projects was to survey the temple’s members about their most important health concerns and then develop programs targeted to those needs.
“Heart disease, allergies, and weight loss were some of the top concerns the community identified for us,” Vyas says. “Diabetes is a very big concern. And it’s not specifically the Hindu community that’s so affected by this disease,” she points out. “It’s [Asian] Indian people in general. Diabetes is more of a concern for us as a race, I would say.”
Being able to work side by side with a community liaison like Vyas makes it easier for both Robinson and Carolinas HealthCare System to serve the local Hindu community in culturally sensitive ways. “When we formed the partnership, I told Chidaabha, ‘I’m of Christian faith, so you will have to help me to be able to meet the needs at the Hindu Center,’” Robinson says. One cultural lesson she learned early on is that some members of this community may be uncomfortable with the idea of placing a terminally ill family member in hospice care.
“Again, this is more of an Indian cultural issue than a religious one,” Vyas stresses. “Some of us do not believe in speeding up the process of death. We believe death will come when it will come. Having a connection between our temple and the hospital system through the FCHM program is very helpful, because we can let them know that when an Indian family is resisting hospice it’s because there is a real cultural dynamic going on.”
A Higher Power
Praying isn’t enough to make America’s health disparities crisis go away. But by educating, advocating, and integrating spirituality with health in all the diverse settings where people gather together to pray, faith community nurses have the power to bring about real change.
“Because of our partnership with Sheila and the FCHM, something is happening at the Hindu Center now that was never happening before,” Vyas reports. “It has helped us develop a culture that prioritizes health. Before, health was thought of as more of an individual responsibility. But now, we’re beginning to develop a connection with our members based on the idea that ‘you are responsible for your own health, but the temple is here to help you be responsible for your health.’”
Jackson adds: “My pastor has told me, ‘I know that you’ve saved some lives in this congregation. I know that I am a healthier person myself because of all the education you’ve provided in the church.’ I can look out into the pews and show you people who were not going to the doctor, who weren’t taking their medicine, and who are now routinely seeing a physician. That’s at the heart of what a faith community nurse can do.”
The great circle of life: It’s the lesson that Simba, the young lion cub in Walt Disney Pictures’ The Lion King, learns as his story unfolds. When Simba loses his father, his view of life changes and eventually he comes to accept “akuna matata”–no worries—as his philosophy. The animated classic illustrates how life has a beginning (birth) and an end (death), but what we encounter in between greatly influences our perceptions.
Of course, life and death are far too complex to be neatly packaged like a children’s movie. But the cultural attitudes, traditions and beliefs we encounter in our lives do affect how we approach these major events. From welcoming a new baby into the family to witnessing the passing of a loved one, it’s at these highly emotional times when we turn to others–such as family, community and health care providers–for support and guidance. It is also at these times–particularly at the end of a life–when nurses can make their greatest impact and perhaps reaffirm their decision to become a nurse.
According to the 2000 U.S. Census, one out of every four Americans is non-white. The traditional American melting pot of assimilation that characterized much of the 20th Century has today evolved into a colorful garden of racial, ethnic, cultural and religious diversity. Because virtually every culture has its own distinct beliefs, customs and practices concerning death and dying, the nation’s health care profession is recognizing that it can no longer take a one-size-fits-all approach to caring for the terminally ill.
By choosing a career in the emerging field of end-of-life (EOL) care, nurses of color can make an exceptional contribution to providing minority patients and their families with culturally competent and sensitive care at a time in their lives when they have never needed it more.
Accepting the End
Most nurses have resigned themselves to the reality that, throughout the course of their careers, some of their patients will lose their battle against illness and disease. Whether it’s a prolonged fight against cancer or the unexpected tragedy of a brain aneurysm, death is an inevitable part of health care. Traditional training, however, teaches health care providers that they must use every available resource to try to thwart a fatal outcome. This is a cornerstone of nursing education and is aided by the constant influx of new, life-saving technology.
It’s not surprising, therefore, that throughout much of the last century, health care providers received very limited education on how to help patients cope with the end of their lives. Helping the dying prepare for that transition was most often left to religious counselors or the patient’s family. But that is changing now, as more health care professionals find their roles evolving to include caring for patients’ needs at all stages of their illnesses.
“It’s not necessarily the length of a life that’s important, but the quality of life,” says Polly Mazanec, RN, MSN, AOCN, a clinical nurse specialist at the Hospice of the Western Reserve in Cleveland. “As nurses, we have been trained in the high-tech ways of keeping people alive, but now we’re also learning how to help people die comfortably and with minimal pain.”
One of health care’s more well-publicized efforts to focus directly on end-of-life issues was the emergence of hospices nearly 30 years ago. Generally speaking, a hospice is a “serene,” compassionate environment in which terminally ill patients can spend their last days in dignity and freedom from pain. Hospice staff are trained to ease suffering, manage diseases’ symptoms and provide emotional support to critically ill patients and their loved ones so that they can be comfortable and reach a sense of peace.
“With end-of-life care, we have to switch from a cure-oriented mode of practice to one of comfort and support,” explains Mazanec
The popularity of this approach to end-of-life care is evident in the growing number of hospice facilities nationwide. According to the National Hospice and Palliative Care Organization (NPCO) in Alexandria, Va., an association representing hospice and palliative care programs and professionals, its member facilities admitted 700,000 patients in 1999–up from 540,000 in 1998.
Interestingly, the majority of hospice patients are white–83% in 1995, says NPCO. The organization estimates that in 1995 only 8% and 3% of hospice patients were African American and Hispanic, respectively.
Why the disparity between the majority and minority populations? Many health care experts point to culture as one of the major contributing factors.
Respecting Cultural Differences
Patients’ cultural norms and beliefs play an important role in their health care decisions–from seeking out a provider to complying with treatment instructions to their ability to communicate with caregivers. This is especially true with end-of-life care, because the patient often brings with him or her a lifetime of perceptions.
For More InformationEnd-of-Life Nursing Education Consortium (ELNEC) Project
Nicole Brown, ELNEC Project Assistant
American Association of Colleges of Nursing
One Dupont Circle, NW, Suite 530
Washington, D.C. 20036
(202) 463-6930, ext. 240 [email protected]
www.aacn.nche.edu/elnecNational Hospice and Palliative Care Organization (NPCO)
1700 Diagonal Road, Suite 300
Alexandria, VA 22314
(703) 837-1500 [email protected]
www.nhpco.orgThe D.C. Partnership to Improve End-of-Life Care District of Columbia Hospital Association
(202) 682-1581, ext. 3221 The Project on Death in America (PDIA)
Open Society Institute
400 West 59th Street
New York, NY 10019
“A patient’s vulnerability is intensified at the end of his or her life, so health care providers must be careful to respect cultural differences,” comments Diana Harris, MA, a research associate in the Department of Ethics and Health Policy Initiatives at the Albert Einstein Healthcare Network in Philadelphia. The department has been examining end-of-life care issues in culturally diverse communities with staff, patients and local community and religious leaders.
In minority communities, traditional cultural beliefs and customs surrounding death and dying can hold extreme importance for patients and their families. Depending on the culture, death may call for loud, open wailing, chanting or quiet contemplation.
“Culture is very important and I don’t think it’s being given the consideration it deserves when it comes to end-of-life care,” says Gwen London, executive director of The [Washington] D.C. Partnership to Improve End-of-Life Care. “I don’t think the current health care system is set up to deal with cultural differences.”
Culture, however, isn’t simply defined by race, ethnicity, gender or religion, experts contend. Rather, it’s a combination of all these factors plus many more, including socioeconomic status, education and, especially for immigrant groups, level of acculturation to the American way of life.
“Nurses have become cultural brokers in health care,” notes Carolyn Bloch, RN, MSN, CNS, a certified transcultural nurse specialist and transcultural/diversity consultant with the Los Angeles County Department of Health Services, Office of Diversity Programs, along with her twin sister, Carol Bloch, RN, MSN, CNS. “Nurses can introduce immigrant patients to American health care procedures, but the patients come with their own cultural views, and nurses must find a balance,” Carolyn explains. “This is especially important with issues of death and dying.”
Finding comfort in religious traditions is another way patients and their families cope with death and dying. For example, Catholics believe it is important to receive Holy Communion and Last Rites by a priest during their final hours. In Judaism, it is a sign of respect for relatives and friends to watch as a loved one passes away. And Buddhists, with their belief in reincarnation, may use chanting to calm the patient’s state of mind at the time of death because they believe this will impact the person’s character at rebirth.
Nurses must be aware of these beliefs and practices so they can attend to dying patients’ spiritual needs in the proper way, notes Alice Cornelison, RN, PhD, an assistant professor and assistant to the associate dean for clinical affairs at Howard University in Washington, D.C., a Historically Black University. For example, she says, Muslims believe the dying person should be turned toward Mecca before and after death.
Religion, however, is not the only cultural element affecting how people feel about death. Sometimes, it’s an ancient custom or belief that has carried on through generations. The Bloch sisters point to a case of a Chinese-American physician who was diagnosed with cancer. According to his family’s cultural beliefs, the sick member must not know or be told of his condition for fear of saddening the spirit and bringing death even sooner.
“Because he was a doctor, this man had been the family member who made all the decisions regarding health care,” explains Carol Bloch. “But when he became sick, he had to relinquish the role of decision-maker. His culture demanded that he not know he was dying.”
This, of course, is the opposite of the American philosophy that the patient has a right to know about his diagnosis and prognosis in order to make decisions about treatment options. In this man’s case, Bloch says, health care providers communicated with designated family members and not the patient. The Blochs also cite the example of a Persian immigrant patient whose beliefs required that a dying person not be told of his condition. This was so important to the family that a relative stood guard outside the hospital room door to make sure the patient was not told what was happening.
Hispanic culture holds similar beliefs about preventing the spirit from hastening death, which is why many families in Hispanic communities opt to have a loved one pass away at home, rather than in the hospital. Here, too, the patient’s extended family is often responsible for making treatment decisions. For example, it’s not uncommon for a wife to defer her health care choices to her husband or to family members to be made as a group.
In contrast, other cultures may welcome a more interventive approach, seeking out life-prolonging technology and the hospital environment. Depending on past experiences, some patients may want full control over their treatment decisions, including employing every plausible option.
However, says Harris, some minority patients have concerns about whether they will receive the same quality of care and the same range of treatment options that are offered to white individuals. “Some of this apprehension,” she adds, “doesn’t just arise with the issue of end-of-life care, but may have been rooted very early in their lives.”
This is particularly true with African Americans. In some black communities, there is an overall distrust of the health care system, which may be a reason behind the small percentage of African Americans who opt for hospice care.
While some of these generalizations may seem like stereotypes, and may not apply in all cases, Carolyn Bloch believes that culturally knowledgeable nurses are better equipped to find the most appropriate way to assist all parties involved with end-of-life care–the patient, family members and even other health care staff.
“If they know that Hispanics tend to refer to the family unit, nurses can relieve a lot of anxiety for the patient simply by asking, ‘Would you like to have your family here with you?’” she notes. “Also, incorporating those cultural aspects into a treatment program can help decrease the nurse’s anxiety, because you’re not struggling with trying to change the patient into doing things ‘the American way.’”
When in Doubt, Ask
Even if EOL-care nurses share the same ethnic or cultural background as a particular patient, or have extensive knowledge of that culture, experts caution that they should resist the temptation to make blanket assumptions about a terminally ill patient’s preferences and needs.
“Although a patient may belong to a certain [cultural] group, he may not follow all the practices,” comments Mazanec. “That is why it’s so important to ask questions to find out what he, as an individual, wants at the end of his life.”
Furthermore, nurses have so many duties to fill their shifts that they may not have extra time to storehouse multiple facts about multiple cultures. “It isn’t possible, or even reasonable, to expect every health care provider to be fluent in multiple cultural traditions,” Harris agrees. “But I do think it’s essential for caregivers to have respect for cultural differences and to listen.”
Adds Mazanec, “I don’t think we always need to have cultural matching between patients and nurses to achieve quality end-of-life care. Nurses just have to be able to ask the right questions and treat all patients’ beliefs with respect.”
End-of-life experts agree that asking questions is the most efficient method of discovering how culture could impact a dying patient’s care. Non-threatening questions such as “What did you do for a living?” can yield very telling responses. Questions regarding family members or friends can help nurses determine whom the patient wishes to have near him at this stage. Even a direct approach, such as asking “Is there anything you want me to know about your beliefs or customs while I’m taking care of you?” can immediately explain to nurses how they can incorporate a cultural perspective into their treatment. These questions need not take up huge amounts of time. They can be asked while bathing patients or administering medications or simply while carrying out other nursing responsibilities.
“It’s important to have these conversations with patients and their families in order to understand what they need,” Mazanec emphasizes.
Harris adds this advice: “While facilitating these discussion, however, nurses should not bring their own frustrations or biases to the table.”
Nursing educators are working hard to facilitate end-of-life discussions within the profession so that nurses can become better equipped to help patients at this crucial stage of their diseases. As an example of the lack of knowledge currently available to health care providers, Mazanec cites a recent study of nursing and medical textbooks that revealed that only 2% of the books contained references to EOL care.
To change this situation, in February 2000 the American Association of Colleges of Nursing (AACN) established the End-of-Life Nursing Education Consortium (ELNEC) Project with a grant from The Robert Wood Johnson Foundation. Among the national program’s objectives is to help schools of nursing incorporate end-of-life care information into their curricula.
In collaboration with four nationally recognized nurse experts on end-of-life care, ELNEC has developed a comprehensive EOL-care course curriculum, including supplemental faculty materials such as outlines, Power Point overheads and additional readings. The course is organized into nine content modules, including one devoted exclusively to cultural considerations in EOL care (see sidebar). To date, the ELNEC course has been presented to representatives from nearly all of the 50 states, who, in turn, have taken the information back to colleges and universities in their areas.
“[Schools] are realizing that this is not simply an elective choice but an essential piece of the nursing education program,” says Mazanec.
ELNEC also has recently begun to contact hospitals’ staff development departments and continuing education authorities to provide working nurses with an orientation to end-of-life care, because many of these nurses may not have had exposure to EOL issues while they were in nursing school. “Too much end-of-life content is being learned in on-the-job training after graduation,” comments Cornelison.
Other organizations, too, are examining how they can assist nurses and other health care providers with developing end-of-life care skills. In the nation’s capital, the District of Columbia Hospital Association joined with local health care educators, community leaders and others to form The D.C. Partnership to Improve End-of-Life Care. One of the partnership’s multiple task forces, spearheaded by the nursing school deans at Georgetown University and Howard University, is addressing ways to expand the EOL education options currently available to health care professionals. One result of these efforts is the creation of an EOL-care course–a collaboration between the participating schools–which is being offered in the D.C. area for the first time this fall.
Through a combination of specialized education and cultural sensitivity, nurse can make a difference in creating a peaceful end-of-life experience for patients and their families. By creating a positive and understanding environment where patients of all cultures can complete the circle of life in their own ways, nurses can take part in a profound human experience and reaffirm the dedication to taking care of others that brought them to nursing in the first place.
A Model for Culturally Competent End-of-Life Care Education
In this nine-module EOL-care curriculum developed by the American Association of Colleges of Nursing (AACN)’s End-of-Life Nursing Education Consortium (ELNEC) Project, cultural considerations are not an afterthought but an essential component of the program:
Nursing Care at the End of Life: Overview of death and dying in America; principles and goals of hospice and palliative care; dimensions of and barriers to quality care at EOL; concepts of suffering and healing; role of the nurse in EOL care.
Pain Management: Definitions of pain; current status of and barriers to pain relief; components of pain assessment; specific pharmacological and non-pharmacological therapies, including concerns for special populations.
Symptom Management: Detailed overview of symptoms commonly experienced at the EOL; for each symptom, the cause, impact on quality of life, assessment, and pharmalogical/non-pharmalogical management.
Ethical/Legal Issues: Recognizing and responding to ethnical dilemmas in EOL care, including issues of comfort, consent, prolonging life, and withholding treatment; euthanasia and allocation of resources; legal issues, including advance care planning, advance directives, and decision making at EOL.
Cultural Considerations in EOL Care: Multiple aspects of culture and belief systems; components of cultural assessment with emphasis on patient/family beliefs about roles, death and dying, afterlife, and bereavement.
Communication: Essentials of communication at EOL; attentive listening; barriers to communication; breaking bad news; and interdisciplinary collaboration.
Grief, Loss, Bereavement: Stages and types of grief; grief assessment and intervention; the nurse’s experience with loss/grief and need for support.
Achieving Quality Care at the End of Life: Challenge for nursing in EOL care; availability and cost of EOL care; the nurses’ role in improving care systems; opportunities for growth at EOL; concepts of peaceful or “good death,” “dying well” and dignity.
Preparation and Care for the Time of Death: Nursing care at the time of death, including physical, psychological and spiritual care of the patient, support of family members, the death vigil, recognizing death, and care after death.
Source: American Association of Colleges of Nursing, ELNEC Project, April 2001