Hindu Dietary Practices: Feeding the Body, Mind and Soul

Hindu Dietary Practices: Feeding the Body, Mind and Soul

A love of nature and the importance of living a simple, natural life are the basis of Hinduism, a faith that originated in India and is generally acknowledged to be the world’s oldest and third largest religion. Like Buddhism, the Seventh-day Adventist Church and other religions that promote a vegetarian lifestyle, the Hindu faith encompasses a number of health beliefs and dietary practices arising from the idea of living in harmony with nature and having mercy and respect for all of God’s creations.

Followers of the Hindu religion, which is practiced primarily in India, Nepal and Sri Lanka, believe that the body is made up of natural elements: earth, air, fire, water, etc. The proper balance of these elements indicates good health, while an imbalance indicates the opposite. Hindus believe self-control and meditation is the path to health, with prayer to the Almighty God being the last resort. For many Hindus, yoga is a means by which to bring the integration of the body, mind and intellect together in order to achieve perfect harmony or alignment.

The four Vedas (which means “the Wisdom and the Knowledge”) are among the most important of the Hindu holy books. For devout believers, these sacred texts address every aspect of their lives that are controlled by their faith, including their daily practices, their yearly calendar and their use of water in acts of worshipping. For Hindus, water is believed to be a purifier and a rejuvenating agent for religious acts, as evidenced, for example, in the traditional practice of bathing in sacred rivers during pilgrimages.

The Hindu Dietary Code

Devout Hindus believe that all of God’s creatures are worthy of respect and compassion, regardless of whether they are humans or animals. Therefore, Hinduism encourages being vegetarian and avoiding the eating of any animal meat or flesh. However, not all Hindus choose to practice vegetarianism, and they may adhere to the religion’s dietary codes in varying degrees of strictness. For example, some Hindus refrain from eating beef and pork, which are strictly prohibited in the Hindu diet code, but do eat other meats.

Like Buddhists, Hindus believe that food affects both body and mind. Food is considered to be a source of the body’s chemistry, which affects one’s consciousness and emotions. Thus, expression of the soul depends on the body, which depends on the food. A proper diet is considered vital for spiritual development in Hinduism. The Hindu diet code divides food into three categories, based on the food’s effect on the body and the temperament:

  • Tamasic food is leftover, stale, overripe, spoiled or other impure food, which is believed to produce negative emotions, such as anger, jealousy and greed.
  • Rajasic is food that is believed to produce strong emotional qualities, passions and restlessness in the mind. This category includes meat, eggs, fish, spices, onions, garlic, hot peppers, pickles and other pungent or spicy foods.
  • The most desirable type of food, Sattvic, isfood that is non-irritating to the stomach and purifying to the mind; it includes fruits, nuts, whole grains and vegetables. These foods are believed to produce calmness and nobility, or what is known as an “increase in one’s magnetism.”

Hindus believe that for true service to God, purity of food is necessary to maintain the desirable state of mind that leads to enlightenment. Food is consumed not only to survive but also to stay healthy and maintain mind/body equilibrium. By eating a purer quality of food, such as a Sattvic diet, and regulating food consumption, one can ensure a pure heart, long life, cheerful spirit, strength, health, happiness and delight. Good and pure food promotes a peaceful—not agitated—mind, which is needed to see the Truth as the Truth. Sin, or an agitated state of mind, prevents the journey to moksha (divine supreme knowledge, which leads to freedom from the cycle of birth, life, death and rebirth).

Some specific Hindu dietary customs and practices include the following:

  • A true devotee will refuse to accept any food that is not offered first to God. Gaining God’s blessing before consuming the food is essential. Hindus may do this is by placing their daily food before the particular deities they worship and by reciting shlokas(prayers). Once the food is offered to God, it is eaten as prasador blessed food.
  • Before starting any daily meal, a devout Hindu first sprinkles water around the plate as an act of purification.
  • Five morsels of food are placed on the side of the table to acknowledge the debt owed to the devta runa (divine forces) for their benign grace and protection.
  • For a child’s birthday celebration, the sacred symbol “OM” is added onto the birthday cake along with “Happy Birthday.” Also, a lamp is lit instead of having the child blow out the candles. In the Hindu faith, lighting a lamp is symbolic of new life, a new beginning or the spreading of knowledge.

The Practice of Fasting

Some Hindus practice the tradition of fasting during special occasions, such as holy days, new moon days and festivals. As is also the case in a number of other religions, fasting is seen as a way of staying close to God and attaining a close mental proximity to Him. Hindus fast in various ways, depending on the individual: They may choose to not eat at all during the fasting period, or to eat only once, eat only fruits or restrict themselves to a special diet of simple foods.

Fasting is believed to help reinforce control over one’s senses, squelch earthly desires and guide the mind to be poised and at peace. Hindus also believe that when there is a spiritual goal behind fasting, it should not make the body weak, irritable, or create an urge to later indulge. Rather, rest and a change of diet during the fasting time is considered to be very good for the digestive system and the entire body. The idea is that every system needs a break and an occasional overhaul to work at its best.4

Health Considerations of the Vegetarian Diet

There is a myth that vegetarians suffer from vitamin deficiencies. The truth is that all needed nutrients are found in vegetables, fruits and nuts when eaten in sufficient amounts; the only exception is vitamin B12. To overcome this potential deficiency, which can cause anemia and other disorders, vegetarians need to markedly increase their protein intake. According to the recommendation of the American Dietetic Association (ADA), vegetarians should increase their consumption of rice milk, soy milk, yeast extracts and breakfast cereals to ensure a sufficient intake of vitamin B12.

Some vegetarians refrain from eating meat, fish or fowl but do consume eggs and/or dairy products. In contrast, a vegan diet is a total vegetarian diet that excludes any and all animal products (i.e., no meat, eggs and dairy). Therefore, vegans generally have a lower calcium intake than non-vegetarians, but they may have lower calcium requirements as well. Vegans are advised to increase their intake of Omega-3 fatty acids found in flax seed, walnuts, soybeans and dark green vegetables.

The ADA is just one example of a major health organization that recognizes that a well-planned vegetarian or vegan diet can reduce the risk of many chronic conditions, such as heart disease, obesity, diabetes, asthma, high blood pressure and cancer. Because vegetarians are less susceptible to major diseases, they can live healthier, longer and more productive lives, with fewer visits to doctors, fewer dental problems and lower medical bills.

Here are some additional health benefits of the vegetarian diet:

  • Food is easier to digest, provides a wider ranger of nutrients and requires less effort to purify the body from its wastes.
  • Vegetarians’ immune systems are stronger, their skin is less flawed and their bodies are more pure and refined.
  • Finally, because meat is expensive compared to fruits, vegetables, etc., a vegetarian diet can also have financial benefits for low-income populations. Unfortunately, lack of sufficient access to food stores that sell good quality fresh produce continues to be a serious health problem in disadvantaged communities.

Editor’s Note: Previous articles in the culturally competent dietary assessments series, including “Meeting Jewish and Muslim Patients’ Dietary Needs” and “Understanding Buddhist Patients’ Dietary Needs,” are available online.

Keeping Up with Changes in the Health Care Industry

Keeping Up with Changes in the Health Care Industry

As nurses, you know that health care is always changing. Nursing is not the same profession today as it was when you started five, ten, or twenty years ago. Part of these changes steep in a better or evolved understanding of what it means to care for patients, but others are out of nurses’ control and reflect changes both in the health care industry generally and in-patient populations.

The introduction and expansion of new tech in the health care setting combined with the rapid rate of change in patient populations mean that nursing is more dynamic than ever before. And you need to keep up.

What are the most pressing changes nurses are facing right now? These are a few of the things that will change the way you practice your profession over the next few years.

Nurses Will Need to Balance the Hands-on/Hands-off Approach

Nursing is, by definition, a very hands-on practice. Care requires a nurse to be wholly present with a patient. But some of that is already changing, and the rate of change could grow substantially over the next few years. Why? Because the Internet of Things (IoT) and all its sensors are gaining ground in hospitals and clinics.

Wearable tech and smart sensors have the ability to record and remotely transmit health data from patients directly to care providers. Everything from vitals to movement is now trackable with current tech, and nurses are increasingly responsible for patients who use it.

The implications are huge for nurses. On one hand, nurses can spend less time on rote tasks, which will make a difference in daily activities and relieve a small amount of pressure as nurses deal with a continued labor shortage. At the same time, it will also change the way nurses care for patients: how will nurses provide bedside care if they no longer need to attend to patients at their bedside?

Nurses Will Find New Colleagues to Work With

Nurses work as a team with physicians, specialists, and administrative staff to keep their organization functioning. However, the continued introduction of new technology in the health care industry will demand nurses to work more closely with two emerging groups: IT professionals and medical coders.

New technology in hospitals means organizations will require an influx of IT professionals to keep all the tech up and running. For nurses, it means working with this group when they find issues with the tech used on the ground.

At the same time, the growth of IT professionals in clinical settings offers an opportunity for nurses. They will help nursing staff stay at the forefront of tech and learn how to balance patient care with technology in a way that’s effective and safe. Working closely with IT teams can also help nurses better protect vital health data and avoid HIPAA violations by avoiding simple mistakes and identifying vulnerabilities.

Patient Self-Advocacy Will Continue to Grow

The role of the nurse as an advocate will also be challenged over the next few years. Already, patients have benefited from advancements like AI and wearable tech. However, as more and more companies insert themselves into the American health care system, the role of the patient as a self-advocate will also begin to grow because they have new resources outside the hospital and clinic system.

Improved self-advocacy is good news for patients and nurses alike. Nurses do their best to encourage patients to ask questions, seek answers, and share their health goals. A more educated and self-empowered patient population benefits everyone, and self-advocacy is a key indicator of patient satisfaction.

However, you can expect to also see it challenge the role of the nurses. Self-advocacy is also empowering non-health care businesses to get involved in certain items. For example, Amazon now allows customers to use their Health Savings Account (HSA) funds to pay for certain items. Nurses will need to adjust to the potential of patients taking on more of their care outside the purview of a clinic. And Amazon isn’t just interested in selling diabetes supplies: you could see giants like these trying to insert themselves into catastrophic disease management and treatment.

Patients Will Be More Diverse in Almost Every Way

Already, nurses need to have a strong understanding of caring for diverse patient populations. However, the changes in demographics, social systems, and epidemiological patterns will only continue, and nurses need to prepare themselves to care for increasingly diverse patients and learn to navigate the ethical challenges that can come with adapting to new patient populations.

Nursing in a diverse context means doing more than providing interpreters and using intake forms in multiple languages: though, these things are vital first steps. It also means learning about the most prominent patient groups and to gain a better understanding of their social, cultural, and religious contexts.

For example, if caring for an elderly Hindu woman, a nurse may find that they need to be specific when they require the woman to fast. In Hindu culture, fasting is part of a religious practice but it can allow them to eat fruit and drink water. Nurses need to be specific about what ‘nothing by mouth’ means. The difference is important and could dramatically impact a patient’s outcomes.

How Will Nursing Challenge You?

These upcoming changes in the health care industry will change the way you practice nursing once again. The addition of new tech, changes in the shape of self-advocacy, and shifts in patient populations all present both opportunities and challenges for both nursing and health care as a whole.

Most importantly, these changes can help you and your colleagues be better, more dynamic nurses and contribute to improved health for your communities. So, don’t fear these changes. Embrace them. If anyone can meet the challenges facing health care over the next few years, it’s nurses.

Come All Ye Faithful: Diversity in Faith Community Nursing

Come All Ye Faithful: Diversity in Faith Community Nursing

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.”

 

Professional Nursing in Oman

Professional nursing in the Middle Eastern nation of Oman has grown rapidly since the country’s 1970 modernization of its health care system. In fact, over the last 10 years nursing has become one of the fastest-growing professions in the country. Previously, nursing education was primarily vocational training, but since 1990 nurses must earn a diploma to practice as an RN. Despite many recent efforts to improve nursing education and practice, the profession is still attempting to catch up with nursing practices in the United States and other nations.

Oman is currently struggling with a rapidly growing population, rapid expansion of health care services and severe shortages of well-trained nurses to meet the demands. The Ministry of Health has made great strides by supporting nurses’ educational preparation, establishing and funding educational institutions and offering free education to individuals who choose nursing as a profession.

The Sultanate of Oman is located in the Persian Gulf region, bordered by the United Arab Emirates and Saudi Arabia on the west and by the Republic of Yemen on the south. It is divided into four governorates (country subdivisions) and eight administrative regions. About 82% of the country consists of sandy desert and rugged mountains with small agricultural areas. Muscat City, inhabited by more than 600,000 people, is the capital and the center of political, economic and commercial affairs. Nizwa, Salalah, Sohar and Sur are other large cities. Oil is the main source of the country’s income, followed by industry and natural gas. According to the 2004 national census, Oman’s total population was 2.57 million, with 33.3% of the population under 15 years old and only 2.2% aged 65 and older. Life expectancy is 74.3 years.

Oman is an Islamic Arabic country that developed its own branch of Islam, called Ibadhism. It is the only country in the Islamic world with a majority Ibadhi population. There are no major variations in the Muhammadan law between Ibadhism and other branches of Islam, such as Shia and Sunni. However, Ibadhism is known for its moderate conservatism and its choice of ruler by communal consensus.2 Although other branches of Islam exist in Oman, there is a unity in the society between all branches, and the country is known for its tradition of religious broadmindedness.3 In addition to the largely Muslim population, there is also a minority of expatriate non-Muslim groups, primarily Christians and Hindus.

Religion and culture play important roles in Oman’s health care practices, regulations and professional roles. Most hospital treatment areas are divided into male and female sections. In outpatient facilities, male patients are treated in the men’s allocated areas and female patients are treated in a different designated area. Inpatient care is similar, with male and female patients admitted into separate wards. However, exceptions sometimes occur in areas such as adult intensive care, coronary care and dialysis units.

Oman’s Health Care Renaissance

Before 1970, Oman’s health care system was one of the poorest in the world. The mortality rate was high, especially among infants and children, with infant deaths estimated at 159 per 1,000 live births.4 Many people suffered from infectious and communicable diseases due to lack of health care services, inappropriate treatment and poor sanitation. Malaria, mumps, trachoma, diphtheria, neonatal tetanus, polio, gastroenteritis and diarrhea were among the most common diseases at that time.5

In July 1970, Oman’s ruler, Sultan Qaboos bin Said, began to take steps to relieve his people’s suffering by seeking to establish an excellent health care system. He issued a royal decree to create the Ministry of Health (MoH), which was charged with the responsibility of providing high-quality health care to all Omani citizens. In the years that followed, the MoH established hospitals and health centers across the country and brought modernization into all health care professions.6

As a result, in less than four decades health care services in Oman have expanded throughout all regions of the country, greatly increasing people’s access to care. In addition, the MoH has initiated many public health programs, including a national birth spacing program and health education programs. Since the ministry’s Expanded Immunization Program (EPI) was introduced in 1981, diphtheria, neonatal tetanus and polio have been eradicated.

Oman has a government-funded National Health Service that includes general and speciality hospitals. The MoH is the main health care provider, followed by the Ministry of Defense and the Sultan Qaboos University Hospital (SQUH). According to the 2005 World Health Organization census, the country has 17 physicians per 10,000 population and the proportion of nursing and midwifery professionals is 37 per 10,000 population. Today, nearly 100% of the total Omani population has access to health services, depending on where they live.7

Currently, Oman has 58 hospitals, which are classified as primary, secondary, tertiary or referral. Combined, these hospitals contain 5,270 inpatient beds, which equates to 21 beds per 10,000 population. Fifty-four hospitals are government-supported and provide free health care services for Omani citizens and for foreign nurses working in the governmental sectors. Fee-for-service care is common for foreign workers in the private sector. Royal, University, Sultan Qaboos, Khoula, Al Nahda, Nezwa and Sohar are the largest tertiary teaching hospitals in the country. Royal Hospital is Oman’s largest health care institution, with about 700 beds and continued expansion to incorporate new facilities.

Other tertiary hospitals have inpatient capacity that ranges from 200 to 532 beds. Khoula Hospital is the Sultanate’s central referral hospital for orthopedic, neurological, cosmetic surgery and burn care. Al Nahda Hospital is the main specialty treatment center for ear, nose and throat surgery, eye care, dental and jaw surgery and skin diseases. Royal Hospital is the referral hospital for heart disease, heart surgery and cancer.7

The tertiary hospitals serve as specialty centers, receiving patients from primary and secondary health care services, emergency patients and patients referred from other hospitals for medical management. The secondary hospitals provide primary and secondary health care services with some specialty care, such as gynecology and orthopedic care. Primary care hospitals provide general health services and refer patients to facilities with higher levels of care when specialized treatment is needed.

In addition to the hospitals, there are 897 health centers, dispensaries and clinics spread across the country. These facilities provide primary health care services with a few specialized care units. Health centers, which are usually located in low-populated areas, are staffed by general practice physicians and nurses, who provide services such as vaccinations and pre- and post-natal care.

History of Nursing in Oman

Nursing in Oman is widely recognized as an admirable, caring profession. For centuries, nursing was practiced by untrained household women who used natural remedies to treat the sick and assist with the delivery of babies. In 1904, the first missionary nurses from America arrived in Oman to work in an organized health center. In the 1950s, a small group of U.S. nurses serving in the American Missionary Association in Muscat began training Omani nationals to become nurses. This marked the beginning of modern nursing in Oman.

At that time, the capital city had only two small hospitals to meet the health care needs of the entire population. The American nurses joined the staffs of the two hospitals and in 1959, a six-to-nine-month training program was established at Al Rahma Hospital for 16 Omani nurse trainees. That training center continued to educate nurses until 1970, when the American Missionary Association established a two-year nursing program, Al Rahma School of Nursing, in Muttrah.7

Oman’s modernization opened a gateway for the nursing profession. In 1972, Al Rahma School of Nursing was taken over by the Ministry of Health. The MoH increased the number of nurse trainees at the school and upgraded it to a three-and-a-half-year program offering a certificate in nursing. In 1980, the Directorate of Nursing was established at the MoH headquarters, an official acknowledgement that professional nursing was now seen as a vital aspect of health care.

From the beginning, the Sultanate’s ambitious plans to improve and expand health care services have been hindered by an insufficient supply of nurses, nursing education programs and nursing educators. Therefore, the MoH began recruiting nurses from abroad. Until very recently, most nursing jobs in Oman were held by foreign nurses, primarily from India, the Philippines and Sri Lanka.

For the last 15 years the Sultanate has been working to Omanize the nursing profession by increasing the number of homegrown nurses and nursing schools. In 1998 Oman had 7,453 nurses, of which less than a quarter (24%) were Omani. By 2006, however, the total number of nurses serving in the MoH had grown to 8,278 and 63% of them were Omani. In addition, the nurse-to-population ratio has risen from 32.6 nurses per 10,000 population in 1998 to 37 nurses per 10,000 by 2005. However, despite ongoing efforts to increase the numbers of both national and foreign nurses, Oman’s health care services still have a 30% shortage in nursing staff.

Nursing Education

At the present time, Oman has 12 basic nursing institutes that offer a three-year diploma program. These institutes operate under the administration of the MoH’s Directorate General of Education and Training. Muscat Nursing Institute (MNI) and Oman Nursing Institute are the largest nursing education programs in the country; each graduates about 100 new nurses a year. The other 10 schools, located in different regions of the country, each produce about 35 new nursing graduates per year.

MNI was the first school to graduate diploma nurses and is considered the heart of nursing education in Oman. MNI assists other institutes with curriculum design and educational resources. To ensure consistent quality of nursing education throughout the country, all nursing schools share an identical curriculum with some minor course plan variations. The Nursing Education Board regulates nursing programs, licenses schools and also helps establish curriculum content.

The country’s first baccalaureate nursing program was launched in 2002. The MoH continues to strive to prepare highly educated nurses and improve the quality of nursing care. Currently, there are two nursing schools in Oman that have BSN programs: Sultan Qabos University (SQU) and Niswa University. In addition to the four-year program, both schools also offer a two-year RN-to-BSN program.

Neither master’s nor doctoral programs in nursing are currently available in Oman, but the MoH and SQU intend to begin offering them soon. In the meantime, Omani nurses who earn BSN degrees are sent abroad to gain a graduate degree. Every two years, the MoH sends a group of 20 nurses to the U.S. to do graduate study at Villanova University in Pennsylvania. The majority of these graduate students major in nursing education and the rest study nursing administration. The education specialties emphasized include adult medical-surgical care, pediatrics, community health, and mental health, depending on the student’s area of interest and the MoH’s faculty needs. After completing their graduate degrees, the students return home to either join nursing institutes as faculty members or work at hospitals as nursing administrators or staff development officers.

The MoH also sends nurses to the United Kingdom and Australia for preparation as advanced practice nurses in specialties such as adult critical care, pediatrics, neonatology, nephrology, midwifery and emergency nursing. Graduates of these programs work as nursing educators and clinical instructors in the Oman Specialized Nursing Institute and teach post-basic nursing courses.

Oman currently has approximately 180 bachelor’s-prepared nurses, about 40 of whom have also completed master’s degrees. Many of these nurses who did their master’s studies abroad say they gained tremendous knowledge and experience from being exposed to education and health care systems in other countries. These growing numbers of nurses with graduate degrees are playing important roles in advancing the nursing profession in Oman. They are introducing new ideas in clinical and educational practice and they’re helping to increase the supply of highly skilled nurses available to meet the nation’s health care needs.

However, there are still not enough nurses with advanced degrees to meet Oman’s urgent demand for more nursing faculty. Because of the severe shortage of nursing educators, about 50% of current faculty positions are held by nurses recruited from other countries, such as Jordan, India, the Philippines and England. These foreign faculty work under temporary contracts with the educational institutions. Even with good pay for nursing educators, the faculty shortage continues to be a challenge. Frequent vacancies resulting from the end of these short-term job contracts, and from resignations of foreign educators who want to return home, exacerbate the problem.

Students’ admission to nursing institutes and university nursing programs is based on secondary school grades, passing an English proficiency exam and admissions interviews in Arabic and English. Each year, the Directorate General of Training and Education sets a predetermined number of slots for male and female applicants. Female students usually account for 80% to 85% of the typical nursing class. In fact, the proportion of female to male nurses in Oman is about seven to one.

This uneven gender distribution in nursing classrooms has created problems for men who are interesting in nursing careers. Although male students want to become nurses, they lack opportunities to enter nursing. The MoH’s justification for favoring female students is that female nurses can generally work in any area of health care, including obstetric and gynecology wards or delivery suites, whereas male nurses are prohibited from employment in some practice areas.

All nursing courses are taught in English by nurse educators prepared at the doctoral, master’s or baccalaureate level. The curriculum is designed to prepare nurses for a variety of roles in hospitals, health centers and community health settings. The coursework addresses content areas that prepare students to practice basic nursing—e.g., adult medical-surgical care, pharmacology, obstetrics/gynecology, pediatrics, community health and psychiatric health. Nursing students also take English language courses, nutrition and other basic science courses. The fall and spring semesters are a blend of theory and practicum experiences, while the summer is extensively practicum with few class meetings.

Licensing, Specialization and Research

Currently, the registered nurse is the only qualified level of nursing practice in Oman. To become an RN, students must graduate from a three-year diploma program or a four-year BSN program. After graduation, they are awarded a licensed RN certificate and are eligible to practice nursing. Nurses who graduate from one of Oman’s nursing education institutions are waived from taking the national licensing exam, because passing the course exams and successfully completing the nursing program are considered measures of clinical performance. However, the licensing exam is mandatory for nurses who graduate from programs outside Oman.

Newly graduated nurses employed in most health care services must work under the direction of a supervisor for six months and complete an internship period before they are allowed to work independently. During the internship, novice nurses are assigned to work with experienced RNs who continue to teach, mentor and perform periodic evaluations. These preceptors have at least five years of nursing experience and have taken some specialized training courses.

Recognizing that continuing education is an important part of maintaining high-quality nursing care, in 1977 the MoH began to establish post-basic training programs—i.e., a two-to-three-year clinical for RNs who have completed a basic nursing program.7 These post-basic programs prepare nurses to specialize in specific practice areas that will improve their performance in clinical settings. The first post-basic specialty program offered was in nephrology. To expand specialized nursing education across the country, the MoH has also initiated a four-month on-the-job training program in which nurses work in teaching hospitals to gain practical experience and theoretical knowledge.

In 2001, the MoH opened the Oman Specialized Nursing Institute (OSNI) in Muscat to increase the supply of nurses with specialized skills. OSNI provides an 18-month program of post-basic speciality courses for nurses across the country and awards certificates in several nursing specialities. These include emergency care, midwifery, mental health, nephrology, nursing administration, adult critical care, neonatal and pediatric critical care. The MoH has also expanded the midwifery program, adding three additional programs to train nurse-midwives in other parts of the country. Selection of nurses for these specialized study programs is based on community health needs, MoH priorities, nurses’ clinical achievements and employer recommendations.

At present, there are no formal nursing research organizations in Oman, but the MoH has several research committees that oversee local studies and surveys. These research projects are conducted by teams of health care professionals, including doctors, nurses and other practitioners. Nurses in Oman generally lack the skills, experience, motivation or financial support to undertake research studies in clinical or academic settings on their own. Although there is a great need for research studies about nursing issues in Oman, few such studies have been published. Increasing the number of nurses with advanced degrees would help remedy this deficit.

Nursing Employment

Nurses in Oman work in all types of health care settings. Thanks to the nursing shortage, newly graduated nurses have 100% job availability in one of the country’s health care systems or nursing institutes. Nurses employed by the MoH are guaranteed a job until the age of retirement (60 years).

In most cases, nurses do not have a choice of where they will work. Because most educational institutions and health care facilities are government-owned, graduating nurses are assigned to employment locations based on staffing needs. Furthermore, most graduating nurses cannot express a preference for a particular clinical area or unit. However, nurses who have specialized post-basic training are assigned to work in specialty units, such as intensive care, burns, renal care and dialysis.

Many nurses in Oman work full time in governmental health care facilities, such as hospitals, health centers and clinics. Most of these nurses have a diploma in basic nursing from one of the country’s nursing institutes and some have post-basic program certificates. Few baccalaureate-prepared nurses work in clinical settings.

Most nurses employed in health care facilities work 140 hours per month with eight days off each month. Duty roster plans vary depending on the facility. In some facilities, the work hours are distributed equally among three shifts, but in most cases nurses work more evening and night hours. Due to staff shortages, some employers often demand that nurses work more than the required hours. Extra work hours are generally compensated with time off. Overtime is rarely paid because most nurses prefer time off instead.

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Nursing, like any other governmental job in Oman, has a salary-based pay system. All nurses employed by the MoH are paid equally according to educational degree and years of experience, regardless of the work location. In other words, nurses working in Muscat earn the same salary as those working in rural areas, and critical-care nurses make the same money as those employed in outpatient clinics. RNs with less than five years’ experience are designated as staff nurses and paid the same wherever they work. Nurses are entitled to receive pay raises and job promotions every five years, starting at staff nurse and moving up to senior staff nurse, supervisor and, finally, nurse adviser.

Nurses in Oman often complain about staffing shortages, heavy workloads, lack of job choice and the difficulties of trying to meet their family obligations while working inconvenient shifts. In some hospitals, nurses have no formalized job descriptions and are therefore required to perform tasks that have nothing to do with nursing, such as dispensing drugs after midnight in the pharmacy and completing statistical reports.

While the Sultanate’s continued expansion of health care services, building of new hospitals and population growth are positive signs of progress, there is no denying that these factors also contribute directly to the nursing shortage. When foreign nurses working in Oman return home to care for family members or leave to take positions in other nations, the result is severe understaffing. The MoH has made significant strides in increasing the number of nursing education programs, nursing students and RN graduates, but these measures still seem inadequate to deal with the looming shortages. Professional nursing in Oman has come a long way in the last 38 years, yet it still has a long way to go.

References

1. World Health Organization (2003-2005). “Oman Demographic Indicators.”

2. U.S. Department of State, Bureau of Near Eastern Affairs (2006). “Background Note: Oman.”

3. Oman Information Center. “Primary Health Care in Sultanate of Oman.”

4. Hill, A.G. and Chen, L.C. (1996). Oman’s Leap to Good Health: A Summary of Rapid Health Transition in the Sultanate of Oman. World Health Organization/United Nations Children’s Fund, 1996.

5. Scrimgeour, E.M., Mehta, F.R. and Suleiman, A.J. (1999). “Infectious and Tropical Diseases in Oman: A Review.” American Journal of Tropical Medicine and Hygiene, Vol. 61, No. 6, pp. 920–925.

6. “The Celebration of the Omani Renaissance Day on the 23rd of July 1970.” Ain-Al-Yaqeen magazine, August 11, 2006.

7. Sultanate of Oman, Ministry of Health. “Oman’s Nursing Profession Comes of Age.”

Nurses, Culture and Cancer

Nurses, Culture and Cancer

Among the many challenges of trying to promote cancer screening and early detection in American Indian and Alaska Native communities is the reluctance to speak about it. Some Native people consider cancer to be an automatic death sentence, and some believe talking about it could invite the disease into one’s body.

So when DeAnna Finifrock, MSN, RN, PHN, a trusted public health nurse who for many years has worked on the Fond du Lac Band of Lake Superior Chippewa Reservation in Cloquet, Minn., was diagnosed with breast cancer 11 years ago, she saw an opportunity.

She told people in the community how she had almost missed getting her annual mammogram that year because she was so busy with her job and family, but that fortunately she did make it to the appointment. She openly shared news of her diagnosis and treatment. And she talked about hope and gratitude.

“I said, ‘I want to be there to rock my great-grandbabies. If I had skipped the mammogram that year, I wouldn’t be here talking to you.'”

Her powerful story helped raise awareness about cancer screening and treatment in the community, and today it adds validity to her work managing a Centers for Disease Control and Prevention (CDC) cancer control and prevention grant for the reservation.

“I’ve traveled the cancer journey,” she says. “I know what it’s like.”

Finifrock is an example of how culturally competent nurses can make a major impact in eradicating cancer disparities in minority and medically underserved communities.

Disparities by the Numbers

Although scientific breakthroughs have led to better treatment and survival rates for many types of cancer, these advances haven’t brought equal hope for everyone. Racial and ethnic minorities bear a disproportionate share of pain, suffering and death from the disease compared to the U.S. population as a whole. Consider these statistics:

  • African Americans have the shortest survival and highest mortality rates from cancer than any other racial or ethnic group. In 2005, the death rate for all cancers was 33% higher in African American men and 16% higher in African American women than in white men and women, according to the American Cancer Society (ACS).
  • Although Hispanics get cancer at lower rates than non-Hispanic whites, they are more likely to be in the advanced stages of the disease when they are diagnosed. Even disregarding age and stage of the disease, the ACS says Hispanic men and women have lower survival rates for most cancers than Caucasian men and women.
  • For many years, research had showed lower rates of cancer among American Indians/Alaska Natives (AI/ANs) than in other ethnic groups, but incidence was vastly underreported. Newer figures show cancer incidence rising in this population, with AI/ANs carrying a disproportionate burden from the disease and facing many barriers to treatment. For instance, the average amount of time between cancer diagnosis and treatment is six months for AI/AN women and nine months for AI/AN men, according to Native American Cancer Research (NACR), a community-based non-profit organization headquartered in Colorado.
  • Asian Americans are the only minority group in which cancer is the leading cause of death. They experience a disproportionate share of cancers with an infectious origin and a growing number of cancers resulting from such factors as smoking and unhealthy diet, according to research published in the American Cancer Society’s journal, Cancer.

Efforts to end these disparities through culturally appropriate research, prevention programs, education and cancer care have increased in the last decade. But there’s obviously much more work to be done.

Making Community Connections

“You see the disparities and you ask why,” says Sandra Millon-Underwood, PhD, RN, FAAN, a professor at University of Wisconsin-Milwaukee College of Nursing. “That’s a good question to ask, but maybe the more important question to ask is: ‘What can we do about it?'”

Millon-Underwood, who was recently inducted into the National Black Nurses Association’s Institute of Excellence, has conducted many research projects on cancer education, prevention, early detection and cancer risk management for at-risk and underserved populations. Her focus for the last 30 years has been on getting the word out in plain language to people right where they live.

For instance, a program she designed to promote breast health among African American women addresses the misconceptions and fears that often prevent women from getting mammograms. In this intervention, nurses present culturally specific breast cancer screening, early detection and follow-up programs to groups of women in the places where they work and worship. Audiences have included housekeeping, custodial and dietary staff at hospitals and colleges; childcare attendants at daycare centers; alliances of ministers’ wives; and weekly Bible study and prayer groups at tiny storefront churches, halls and mosques. More than 6,000 women have benefited from the program to date.

A key to reaching people in communities of color is connecting with them at the grassroots level, Millon-Underwood emphasizes. She cites other successful cancer outreach programs in which nurses have presented information to customers at nail salons, barbershops and even laundromats.

To make true connections with people in the community, nurses must first establish trust. “You’ve got to be engaged before you can engage [others],” Millon-Underwood says. “You’re not there just to present a program. You’re there because you care.” She encourages nurses to structure cancer awareness presentations as participatory dialogs rather than one-way lectures, and to stay after group meetings so individuals can approach with questions they may be afraid to ask in front of everyone.

Opening Doors

Personal stories from the community can be powerful dialog openers. Cancer awareness increased substantially on the Fond du Lac Reservation after the community began to participate in the American Cancer Society’s Relay For Life, an annual overnight event that brings people together to celebrate cancer survivorship and raise money for ACS research and programs.

Six years ago, more than two dozen people from the reservation participated in Relay For Life for the first time, walking or running laps to raise funds. Others donated money for luminaria (small lanterns made by placing votive candles in paper bags and weighing them down with sand) to honor loved ones and friends who had experienced cancer.

“It was amazing to walk that path of lighted luminaria. It opened the door so people could start talking about [cancer],” Finifrock says. Today more than 100 Fond du Lac community members take part in the event.

Since then, Finifrock and her public health nursing team have expanded their cancer control activities on the reservation. Through its CDC grant, the reservation created the Wiidookaage Cancer Program. (Wiidookaage is the Ojibwe word for “they help each other.”) The program includes a wide variety of cancer education, screening and outreach activities, with a focus on one-on-one and small-group interventions developed by health professionals who are well known and trusted in the community.

Now Fond du Lac is advising the American Cancer Society on its revision of the national Circle of Life program, which is designed to decrease breast cancer incidence and mortality rates among Native American women through culturally sensitive early detection and screening strategies. The revision, based on the successful programs developed by the Fond du Lac reservation, also addresses other types of cancer in Native communities.

But early diagnosis can only help so much when so many barriers to treatment still remain. For many American Indians and Alaska Natives, obtaining access to the health care system is complicated, and the Indian Health Service suffers from a lack of funding.

“If I had to go through my tribe to get health care after a diagnosis of cancer, I’d first have to move back to Oklahoma and wait six months to establish residency,” says Linda Burhansstipanov, MSPH, DrPH, CHES, executive director of Native American Cancer Research and a member of the Cherokee Nation. “Then I’d have to get on a referral list.” She estimates that it could take as long as 18 months to get treatment under that scenario.

Access to anti-nausea and pain medications is limited, too, and sometimes patients don’t get any information about how to take the medications. A large percentage of patients in NACR’s database report unmanaged cancer pain.

These color-coded reference cards, developed by nurses at University of Texas M.D. Anderson Cancer Center, help palliative care nurses provide culturally competent spiritual care to cancer patients at the end of life.These color-coded reference cards, developed by nurses at University of Texas M.D. Anderson Cancer Center, help palliative care nurses provide culturally competent spiritual care to cancer patients at the end of life.

Cultural barriers can also contribute to pain management disparities in AI/AN patients. For example, some Indian patients may have completely different ways of thinking about, describing and dealing with pain than their non-Indian health care providers. When doctor and patient aren’t on the same wavelength, communication becomes difficult, if not impossible.

“We don’t [like to talk about our pain],” Burhansstipanov says. “Indian patients feel they’re supposed to show stoicism.”

These cultural communication breakdowns can be a problem for other racial and ethnic minority populations as well. In some cultures, a patient may be reluctant to complain about pain because it might imply disrespect toward the health care provider, says Guadalupe Palos, RN, LSMW, DrPH, an oncology nurse and assistant professor at University of Texas M.D. Anderson Cancer Center in Houston, who has conducted cross-cultural research on cancer pain and symptom management.

Spiritually Competent Care

Nurses can also play an important role in providing culturally and spiritually competent care to minority cancer patients in the hospital setting. Nurses in the palliative care unit at M.D. Anderson Cancer Center, for instance, work with hospital administrators to accommodate patients’ cultural celebrations, such as quinceaneras, and honor religious observances, such as Ramadan.

Cancer researcher Jennifer Wenzel, PhD, RN, CCMCancer researcher Jennifer Wenzel, PhD, RN, CCM

Earlier this year, a team of four palliative care nurses at M.D. Anderson, led by Teresa Smith, RN, MS, NP-C, CHPN, developed a set of color-coded reference cards to help nurses and nursing assistants in the medical center’s acute palliative care unit understand patients’ diverse religious and spiritual traditions, especially those involving death and dying. Because about 40% of patients on this unit are at the end of life, preparing patients and their families for death is a daily reality.

Years ago, the prevailing perception was that half of the medical center’s patients were Baptist and the other half were Catholic, Smith explains. But patients now come from all over the world. “I can count on one hand the number of patients I had who were Baptist or Catholic,” she says.

Smith began researching end-of-life spiritual practices for her master’s degree, and the cards developed from there, with input from community religious leaders. Each card covers a different religion, from Hinduism and Islam to Coptic Christianity, and includes details about that faith’s end-of-life rituals. Some Hindus, for instance, tie the dying person’s toes together with colored threads, which nurses should not cut or remove. Some members of the Buddhist faith may want the body left undisturbed for hours after their loved one has died, so they can chant and pray for the deceased person’s soul.

Nurses who lack understanding of a dying patient’s cultural and spiritual needs at this difficult time can make that person’s death an even more traumatic experience for his or her family members. Smith recalls one Hindu family who were deeply upset because a nurse read the 23rd Psalm to their dying family member. The nurse was only trying to help, but the good intentions didn’t erase the family’s pain.

Creating Support Systems

Research is still another area in which nurses can make significant contributions toward closing the gap of unequal cancer outcomes. There is a tremendous need for more minority nurse scientists who can join the ranks of those who are already investigating the causes of cancer disparities—including biological, genetic, socioeconomic, cultural and health care access issues—in order to develop interventions that will improve care for at-risk and vulnerable populations.

For example, Jennifer Wenzel, PhD, RN, CCM, assistant professor at Johns Hopkins University School of Nursing in Baltimore, is currently conducting a mentored research study called “Developing Cancer Navigation Support for Rural African American Elders.” The five-year pilot study, funded by the American Cancer Society, the Robert Wood Johnson Foundation and the National Institute for Nursing Research, will test a community health worker/RN-led intervention designed to help older African American cancer patients in rural Virginia overcome barriers to obtaining quality care and accessing available support services.

Initial focus groups examined cancer survivors’ experiences with navigating diagnosis and treatment, including financial issues and strategies for support. The study is now recruiting African American elders undergoing cancer treatment and asking each of them to identify one support person/caregiver, such as a family member or friend. Community health workers will be trained to provide these caregivers with education and support to help them feel better equipped to deal with the challenges of their role.

This approach is innovative because it focuses not only on the patients but on their caregivers, too. “The health care system places a lot of burden on the person providing support for the patient,” Wenzel says. “The closer that person is to the patient, the harder the situation can be for helping [the patient make it] through cancer treatment.”

The study will look at stress measures and economic and social outcomes. In addition, half of the patient/caregiver pairs will be in a control group that will get survivorship support once cancer treatment is finished.

Palos, too, has conducted research on the impact of cancer on the caregivers of minority and medically underserved patients. Many of these caregivers are under severe financial stress, she says. Often they’re forced to choose which prescriptions to fill when co-pays outstrip their available cash. Psychological burdens take a toll, too, Palos adds. Many caregivers show symptoms of depression but avoid using the word. “They say, ‘I’m not [the one who’s] sick. I shouldn’t be depressed.'”

She has found many similarities across cultural groups in her research, such as the importance of spirituality and the commitment of family members to care for their loved ones going through cancer treatment. Understanding cultural differences is important, too, but Palos cautions nurses not to categorize or stereotype people on the basis of race, ethnicity, culture, religion or other factors. Cultural competence goes beyond broad categories and should include sensitivity to people’s individual values and circumstances, she emphasizes.

Underwood agrees that cancer care providers must never lose sight of the patient as a unique, individual human being. “Sometimes we can get so focused on the machines and monitors, we don’t see the person,” she says.

Twenty years ago, when a landmark American Cancer Society-funded study was released showing that poor people died needlessly from cancer, Cassandra Middleton, a low-income cancer patient, said the doctors who treated her for osteosarcoma of the leg made her feel unimportant because she was poor. At the news conference announcing the study’s results, Middleton told reporters: “They made me feel poor. I know I am, but they made me feel like I am.”

Those words haunt Underwood to this day. She says nurses should ask themselves: “Could that ever have been me?”

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