With more than two million men and women in custody in American jails and prisons, there’s a great need for nurses to care for the correctional population. Nurses who can cast off their biases and follow strict security rules while helping inmates restore and maintain health could find an ideal career in correctional nursing, says Mary Muse, Director of Nursing for the Wisconsin Department of Corrections. “Correctional nursing allows you to really focus on what nursing is: caring for people,” she says. “If nurses want to be autonomous in their position, there’s probably no better setting than correctional nursing.”
Muse, a nurse for three decades, faced common misconceptions and stereotypes early in her career. Many perceive that correctional nurses aren’t held to the same standards as nurses in other health care settings, such as hospitals and doctors’ offices. “It was a job you took when you didn’t necessarily have something else,” Muse says. “This was a nontraditional health care setting.” Vowing to ignore the stigma, Muse made it her mission to enhance correctional health delivery and help eliminate disparities, while making the fi eld more visible. “Nurses who practice in correctional settings have really been absent from the larger landscape of nursing,” she says.
Of the many ways correctional nursing differs from nursing in a health care setting, the most obvious might be the “challenge of caring versus custody,” says Ginette Ferszt, associate professor of nursing at the University of Rhode Island. While nurses come to their work from a caring science perspective, she says, the primary goal in U.S. prisons is custody and safety.
That disconnect makes the role of a correctional nurse even more important, says Pat Voermans, a correctional nurse consultant and nurse practitioner with the Wisconsin Department of Corrections. “What’s so striking to me is the need of the people in these systems,” she says. Inmates can’t choose their providers, and correctional nurses are the gatekeepers to getting prisoners the health care they need. And, she adds, “We can’t choose who we get. Sometimes we get patients who don’t have the best handle on their decision making and how they interact with others. They’re angry and you have to try to work with them. Trust is a really hard thing to establish with an inmate because they often see us as part of security.”
A day in the life of a correctional nurse
Every day is different for a correctional nurse, but many of the nurse’s duties are the same at jails and prisons across the country. In Connecticut, where the Department of Corrections oversees jails and prisons, intake screening is a major responsibility for nurses, says Dr. Connie Weiskopf, Director of Nursing and Patient Care Services for Correctional Managed Health Care at the University of Connecticut Health Center. Correctional nurses in the state perform about 35,000 intake screenings every year, she says, filling out a four-page document on each inmate’s physical and mental health status.
In addition, correctional nurses in Connecticut administer more than one million doses of medication each year, Weiskopf says. “Many of the inmates in the system are on medication. The nurses administer medication to all the patients.” Inmates who were recently released from the hospital are cared for by nurses in the prison infirmary. Other nursing duties include coordinating outside services for inmates and overseeing care management for HIV-positive patients.
When it’s time for an inmate to leave prison, Weiskopf says nurses coordinate with the correctional department to facilitate the patient’s discharge and arrange for continued care and medications on the outside. Nurses also run hospice units within some correctional facilities, and they can play a role in decisions on early release for ailing inmates. “Sometimes there’s a great deal of effort put into compassionate releases,” she adds.
Voermans, who has spent 25 years working in correctional facilities, deals with programs and policies and provides chronic disease management care to male inmates in minimum security settings. The population, often disproportionately minorities, faces chronic conditions such as obesity, diabetes, and liver disease. Lab work is done on-site, and medications are provided by the state pharmacy. With several inmates sometimes crowded into the same cell, infection control is key, Voermans says. “If you get a transmissible disease like H1N1, you’ve got a crisis on your hands.”
Ferszt says some correctional nurses also try to help patients with mental health issues. “They also do a lot of psychosocial support,” she says. Many of the women prisoners Ferszt works with in Rhode Island put in requests to get medical treatment for reasons other than physical concerns, such as anxiety related to the death of a family member.
Correctional vs. health care nursing
Nurses accustomed to working in hospitals or doctors’ offices might fi nd a correctional setting takes some acclimation. Correctional nurses work closely with security officers, Muse says, in an environment much more regimented than the outside. Sometimes, nurses are prohibited from even bringing a cell phone into the prison clinic. “One of the primary differences is the work environment,” she adds. “It’s not necessarily a warm, bright environment. It tends to be dark.
” Even the equipment available to correctional nurses might be different than in a hospital, Voermans says. While nurses in health care settings can often access state-of-the-art tools and the skills and input of other providers, that’s not always the case in a correctional facility. And, in some ways, the extent of care provided might be different in a prison. “The care you give here is medically necessary care,” she adds. “It’s not elective care.”
Weiskopf says interactions between correctional nurses and patients can take on a new quality within prison walls. While a hospital nurse wouldn’t hesitate to tell a patient with a broken leg about her own similar experience, discussing such details is inappropriate in a correctional facility. “You really do not divulge anything personal to prisoners at all,” she says. And while a hospital nurse might hug a patient with dementia, Weiskopf says, a correctional nurse wouldn’t hug an inmate. “You really need to just focus on the care.”
Correctional nurses need to maintain boundaries because of the potential for an inmate to take advantage of a health care provider, Muse says. “You have to be aware that someone might say, ‘I’m really concerned about my mom. I haven’t heard from my mom in a while,'” she says. While a hospital nurse might help the patient reach out to a relative, correctional nurses would be ill advised to accept a request that could lead to more demands from the inmate. Even when it comes to discussing an inmate’s upcoming surgery, correctional nurses should only give family members vague details, since the inmate could be planning an escape attempt. “You have to clearly present yourself as a professional nurse,” she says.
The differences between correctional nursing and nursing in health care settings can lead to challenges. When nurses can’t hug or touch patients, it might be difficult to show empathy, says Arleen Lewis, a nurse consultant for infection control at the University of Connecticut Health Center Correctional Managed Health Care. Instead, correctional nurses can verbally empathize with patients grieving the loss of a loved one or reeling from a disease diagnosis. “We’ll bring that patient to an area where we can maintain confidentiality,” Lewis says, “and we’ll allow that inmate to verbalize his or her feelings.” Patients are encouraged to discuss their fears while nurses express their support and, if needed, bring in mental health clinicians.
Even routine patient interaction can prove challenging in a correctional setting, Ferszt says. When prison nurses perform tuberculosis or fl u clinics, inmates are lined up for vaccinations. But if a patient wants to speak to the provider, there’s not always time for counseling. While the nurse can request for the inmate to be brought back to the clinic for a later discussion, everything moves more slowly due to facility rules and inmates’ tight schedules. “You just can’t be as spontaneous in your teaching,” Ferszt says, “and in communicating with a woman or man when you’re providing health care.”
Patient privacy and safety
Patient privacy is another potential hurdle for correctional nurses. In private practice, Ferszt says, a quiet, calm setting is the most amenable to counseling a patient. But in a correctional facility, it can be tough to find a private room. Even then, other staff members sometimes walk in and out during a session. “You don’t have the same total privacy you would in another setting,” Ferszt says. The same goes for physical assessments, Voermans adds, which sometimes take place in noisy cells as patients wears chains or shackles.
Because correctional nurses work in a security setting, rather than a health care environment, they follow a different set of rules. “You’re basically in the house of the department of corrections,” Weiskopf says. “That means we need to obey their rules around safety.” For instance, while nurses in health care settings might leave needles on the counter in a patient room, she says, correctional nurses are “constantly counting sharps.”
Muse, who hasn’t experienced any safety issues on the job, says it’s important to be mindful of what nurses leave unattended in exam rooms. Even a seemingly innocuous roll of tape, she says, could be used as a weapon. “It doesn’t mean that weapon is to be used on you. For many people, it’s so they have something to protect themselves should they get in trouble.”
As for Muse, she didn’t consider the potential safety hazards of correctional nursing before she started the job. Walking through the correctional facility during her fi rst week, a supervisor mentioned gang activity there, surprising Muse that such affiliations existed behind bars. The supervisor also noted that nurses should greet passing inmates. “They remember the people who were kind and respectful of them,” Muse says. “If you treat people with respect, generally you get that back.”
Diversity in correctional facilities
Despite the challenges of correctional nursing, the compliance rate, at least anecdotally, is sometimes better among the prison population, says Michael Ajayi, a prison administrator and regional nurse manager, and clinical faculty member at the University of Medicine and Dentistry of New Jersey. “I’m sure many of them know they get good care,” he says. “They respond better to therapy than patients who are on the outside.”
It’s estimated that African American and Hispanic prisoners account for more than 60% of the inmates in jails and prisons, according to the Bureau of Justice Statistics. Although the prison population is quite diverse, that isn’t always the case with the staff of correctional nurses. “You see more minority inmates,” Ajayi says, “but almost all the nurses working with them are Caucasian.”
Correctional nurses should be conscious of this diversity and treat all inmates with respect. “With people from so many different places immigrating to our country,” Ferszt says, “we really need to work on becoming culturally aware.” Patients with certain cultural backgrounds might resist taking medication due to their beliefs, while others turn to herbs for healing. Just as in a traditional health care facility, nurses working in corrections should make an effort to understand those beliefs and find ways to work with patients. “It requires a nurse to be proactive and comfortable seeking out individuals from different backgrounds.”
Health risks and challenges
Because correctional nurses work with a disproportionate number of incarcerated minorities, Voermans says health issues particular to the groups might be more likely inside prisons than on the outside. The correctional population sometimes faces higher rates of HIV/AIDS, hepatitis C, MRSA, and even infectious diseases. Working with minorities means correctional nurses can serve as advocates, shining a light on health issues that afflict certain populations more frequently. One example she mentions is sickle cell disease in black patients. Muse also encourages correctional health care providers to consider the unique needs of female prisoners who are sometimes forgotten in the male-focused field. “For a patient to see a minority nurse they can connect to that might advocate for their health is helpful,” she says.
Since language is sometimes a barrier, Weiskopf says health education materials are often available in English and Spanish. Many correctional nurses have access to a language translation line and chaplains of various religions. Her unit has mandatory diversity training for staff. “We try to be culturally sensitive,” she adds.
Not everyone is cut out for correctional nursing. “It’s important to be someone who wants to serve that population,” Ferszt says. “Nurses need to, like anyone, examine their own potential biases toward that population.” Voermans adds that patients can experience bad medical outcomes when their complaints aren’t taken seriously by medical personnel. And as for the nurses, “If they don’t like the disadvantaged and the poorest, they shouldn’t be there,” Ferszt says.
Correctional nurses should be generalists, Muse says, but also ready to cross over into specialty areas. “In correctional nursing, you never know how your patient is going to present.” Correctional nurses should be poised to leap from oncology to mental health at a moment’s notice, Muse adds. Critical-thinking skills and a strong background in nursing assessment are also key. Ferszt says there are other important traits for correctional nurses, including flexibility and the ability to maintain good working relationships with correctional officers and administrators. “The system can be very frustrating because of its structure. You need someone who can be really flexible.”
It’s sometimes tough to recruit new nurses to corrections. But despite the challenge, Muse says, it’s just as important to recruit the right type of nurse, especially to correctional leadership positions. “There is a need to have minorities in more leadership roles,” she adds. Opportunities within the correctional nursing field include positions for advanced practice providers, nurse practitioners, managers, quality assurance personnel, juvenile nurses, and more. For nurses who feel ready for the challenge of practicing in a correctional facility, Ferszt says there’s an unending opportunity to do good for patients. “By realizing the issues they deal with, we can become better advocates for them in the community and change health care,” she says. “There’s an opportunity to make a real, significant impact.”
Over the last decade, there has been talk of an impending shortage of nurses. Even in light of the economic downturn, the soaring demand for more educated nurses is expected to continue as baby boomers age and health care coverage expands. For nurses who are entering or are in the field already, this demand presents an excellent opportunity to advance their careers and expand their knowledge.
So what is the logical next step? Often, it is to obtain an advanced degree. Once the decision to pursue higher education has been made, the next question is where to enroll. As online degree programs have increased in popularity over the last few years, many prospective students may wonder about the similarities and differences between online and traditional nursing programs. Before making your decision, consider what type of institution and program will best suit your needs and situation.
Benefits of an online education
Many nurses say the primary reason they chose an online program is because of the convenience and flexibility. Online learning offers students who are trying to balance a family, career, and other commitments the opportunity to earn a degree without sacrificing their other interests and obligations. An online nursing program may also offer a wider variety of degrees than a local university—if a local university is even an option. Especially in rural areas, the distance and time to travel to a brick-and-mortar institution may make this option impractical.
Another benefit of online learning is the asynchronous environment. In an asynchronous learning environment, students can participate at their convenience instead of being limited to participating at the designated location and the time when a class is offered. In the online format, students can generally post their homework and contribute to discussions when it works best for them. This is an especially important benefit to nurses who work shifts that potentially preclude them from attending traditional classes.
Some nurses believe that enrolling in an online program means losing out on the networking and interaction opportunities that occur in a traditional classroom. While it is true that actual face-to-face interaction is limited, nurses still have the opportunity to connect and network with other professionals online. The online setting also allows students to network with classmates and faculty from across the country and potentially around the world. As a result, nurses have the opportunity to hear about what’s happening beyond their local area, as well as benefit from the practical experience and knowledge shared by colleagues in other locations. The ability to connect with professionals from different practice settings and to share experiences and challenges is also cited as a unique feature of online learning. And other student resources, such as career advisement and even tech support, are typically as accessible and readily available via online universities as traditional.
While it may be the solution for some, online learning isn’t for everyone. There are students who want or need a traditional learning environment. For instance, an online classroom lacks the nonverbal cues that visual learners prefer. Some students simply need the face-to-face interaction. Many feel most comfortable having conversations in person and not over the phone or via an online discussion.
In addition, online and traditional nursing programs have different communication styles. On the job, nurses are taught to be succinct in their writing style because of the volume of required documentation in electronic records and because much of their work is done via checklists. Nurses who choose online education participate in a more intensive writing program than traditional education offers, since nearly all of the communication online occurs in written form. Prospective students should keep their personal communication style and preferred learning format in mind when selecting a program.
For both traditional and online nursing programs, practicum or clinical experience is required. However, practicum arrangements vary by degree program as well as by institution. Undergraduate practicums in face-to-face programs are usually arranged by the institution, while undergraduates in online programs typically propose the facility and preceptor. For graduate practicums, the trend for both online and face-to-face programs is for the student to propose their facility and preceptor.
No back row
Class participation is a very different dynamic in an online program versus a traditional program. In a traditional classroom, faculty members typically lecture, and grades are often based on exams and papers rather than on classroom participation. On the other hand, an online program places greater emphasis on participation: everyone participates in discussions by posting their thoughts—there is no back row.
The asynchronous online environment is an unexpected benefit for many students, because it allows students to think about what they want to say before they actually say it. Online students have time to reflect on the discussion, and they are actually more engaged. Traditional students who fear public speaking tend to stay silent in class, whereas an online setting can help build confidence in shy individuals or help those for whom English is a second language compose their thoughts before speaking.
Above all else, quality
Regardless of the delivery method, it is important that students find a quality nursing program. When researching which program or type of institution is best, one of the first things prospective students should check is the accreditation. The program should be accredited by either the National League for Nursing Accrediting Commission (NLNAC) or the Commission on Collegiate Nursing Education (CCNE). Additionally, the school should also have a Higher Learning Commission (HLC) accreditation if it offers doctoral programs, as Ph.D. programs are not NLNAC- or CCNE-accredited.
Another consideration when choosing a nursing program is to look at the level of faculty preparation and experience. Faculty credentials are important, and faculty members should be teaching in their areas of expertise—as established through both academic preparation and experience. Faculty members should be experts, and they should be certified in their areas of practice.
For an online nursing program in particular, it is important to see how long the institution has been in the business of teaching and offering classes online. Many schools are now offering classes online, but that doesn’t mean that their classes are designed for a truly online experience. To provide a high-quality online nursing program, it is necessary for the school to have expert instructional-design knowledge as well as the technology support that online students need.
Above all, prospective nursing students need to be diligent and research the institution. Talk to an enrollment advisor about the program and the various resources available. Also, reach out to faculty members and current students, as well as alumni who have gone through the program. Ask them questions about their experience, course content, and how the degree has helped them succeed. Prospective students can also check out benchmarks with the American Distance Education Consortium (ADEC), the American Federation of Teachers (AFT), and the National Education Association (NEA) to see if the institution they are interested in enrolling in is meeting those benchmarks.
At the end of the day, there is no significant difference between student outcomes for traditional and online nursing programs. Both can provide a rewarding learning experience, but, ultimately, it is up to the student to determine which program and delivery method are best suited to his or her current situation and needs.
Like many other nursing specialties, nurse anesthesia education programs face the challenge of recruiting, retaining and graduating a sufficient number of qualified students to meet the demands of the health care workforce. A significant aspect of this challenge is the struggle to achieve a racially and culturally diverse student mix that represents the patient population.
The assertion that racial and ethnic minorities are underrepresented in the field of nurse anesthesia does not require sophisticated statistical analysis. One need only visit the meeting rooms and exhibit halls of a professional nurse anesthesia conference to arrive at this conclusion. A recent survey by Dr. Prudentia Worth, director of the Nurse Anesthesia Program at Wayne State University, reveals that only 16% of students in such programs are non-Caucasian.
The Nurse Anesthesia Program at Georgetown University has begun to address this challenge by developing a project designed to prepare more minority nursing students for nurse anesthetist careers. Funded by a grant from the Health Resources & Services Administration’s Bureau of Health Professions, Division of Nursing, the project’s approach is multifaceted, encompassing student recruitment, admissions and, above all, successful completion of the program.
The success of this diversity initiative serves to benefit not only students but also communities that are at the greatest risk of suffering from a shortage of nurse anesthetist professionals. In creating and implementing this project, our goal was to produce a diverse group of graduates with the competencies to deliver cost-effective, culturally appropriate, quality care to all patients.
The project was officially launched in July 2001. As the result of our initial efforts, the Nurse Anesthesia Program’s class of 2003 has more minority students enrolled than any previous class.
Beginning the Journey. . .
The academic journey toward a career as a practicing nurse anesthetist is not an easy one. After earning a bachelor’s degree and licensure as an RN, the nurse must acquire experience in an acute care setting. From there, the formal application and enrollment process into a nurse anesthesia program can begin.
The length of these programs ranges from two to three years, with 27-28 months being the average. The student faces a rigorous course of study, including classes in the basic sciences (e.g., anatomy, physiology, pathophysiology, pharmacology), professional aspects of nurse anesthesia and advanced principles of nurse anesthesia practice. Upon completion of the program and conferral of a master’s degree, the graduate may sit for the certification exam. It is only after all of these steps are successfully completed that a nurse becomes a Certified Registered Nurse Anesthetist (CRNA).
The Georgetown project’s first step in bringing a more diverse group of nurses into this journey was to initiate strategies for recruiting qualified minority RNs into the Nurse Anesthesia Program. This ongoing effort currently includes outreach to members of student associations, state and regional nursing associations, nurses practicing in local critical care units, and minority nurses’ professional organizations, such as the National Association of Hispanic Nurses.
Another key focus of this outreach effort is personal visits by faculty, alumni and admissions recruiters to hospitals that have a high percentage of nurses of color. Students in our program spend 15-16 months in clinical rotations in the operating room, providing anesthesia under the supervision of a licensed anesthetist. Because of a growing need for more nurse anesthetists in the D.C. area, enrollment in Georgetown’s program has risen 400% in the past five years.
This has required an increase in the number of hospital sites students can use to obtain their clinical experience. To dovetail this need with the goals of our diversity initiative, we have sought out new clinical sites that not only provide contact with minority nurses who could be potential applicants to the program but also give students exposure to a more diverse patient population.
Applicant selection is important to the success of a nurse anesthetist education program, in order to minimize the student attrition rate without compromising the professional expertise of the graduates. For this project, we developed a selection tool based on such criteria as previous nursing education, GPA (undergraduate and graduate), GRE scores, number of years of nursing and critical care experience, three references and a personal statement. The process also includes a personal interview with faculty.
The admissions committee then ranks candidates based on their overall presentation, including academic, clinical and personal accomplishments. In addition, the faculty identifies candidates who have potential but may not meet all requirements or have deficiencies in certain areas. For these applicants, the faculty recommends specific actions, such as additional course work or clinical experience, to increase the candidate’s chance of being accepted into the program and completing it successfully.
In 2001, Georgetown faculty and students conducted a pilot study that describes the benefits of providing associate degree nursing students with information about nurse anesthesia as a career path. As a result of this study, our diversity project also focuses on establishing partnerships with local associate degree programs. This provides minority graduates of these programs with information about the field of nurse anesthesia and the opportunity to pursue an advanced degree. Georgetown offers a number of bridge programs for associate degree students, including RN-to-MSN and a second-degree program.
. . .and Finishing It
The philosophy of Georgetown’s Nurse Anesthesia Program is that every effort must be made to ensure that the students who receive their degrees on graduation day are the same students who sat in orientation on the first day of the program. This level of commitment to student retention requires a labor-intensive strategy of evaluation and advisement throughout the course of study.
Program faculty conduct individual evaluations with students at least once each semester. Students who need to improve their performance receive assistance in the form of advising, tutoring and mentoring. In the program’s clinical phase, mentoring is provided by practicing CRNAs. A more formal peer mentoring program for incoming students is also under development. When indicated, faculty provide individualized remediation programs to help students address specific areas of weakness.
A concern of all students is the ability to fund their education, and this is even more critical if the students are economically disadvantaged. The project at Georgetown is addressing this issue by seeking means to increase financial assistance sources for minority students. These sources include future employers who are willing to provide tuition assistance, corporate funding, support within the nursing school and the university, government-sponsored minority scholarships, program traineeships and alumni-sponsored scholarships.
A major initiative to recruit more minority students also requires appropriate resources in terms of faculty and staffing. We have addressed this by increasing the number of full-time faculty, hiring a full-time administrative assistant and using adjunct faculty and teaching assistants to provide supplemental teaching and administrative support.
Another of the project’s goals is to provide role models for the students by increasing the number of minority faculty in the program. Our diversity recruitment efforts at the faculty level include both short- and long-term solutions: recruiting from areas where minority faculty work and encouraging new minority graduates and junior CRNAs to pursue teaching careers.
Although this project is still in its infancy, the initial results are encouraging. At open houses for the Nurse Anesthesia Program this year, 38% of the attendees were nurses of color. And while it is difficult to accurately measure changes in the racial and ethnic makeup of new applicants and enrollees, because 25% of these nurses chose to not specify their race or ethnicity, we have seen increased minority representation in both of these areas between 2001 and 2002.
Other quantitative and qualitative results we will evaluate on an ongoing basis to monitor the project’s success include student feedback, review of the selection tool and of admissions committee comments, enrollment of minority students whose initial nursing degrees were at the associate level and employer participation in tuition assistance programs.
It’s common knowledge that nurses of color play a critical role in bridging cultural gaps between racial/ethnic minority patients and America’s traditionally “white majority” health care system. When minority patients seek treatment, it’s only natural that they feel more comfortable when nurses or doctors share their cultural heritage.
But just because patients and their health care providers are members of the same ethnic minority group doesn’t mean that cultural conflicts don’t arise. Many intra-ethnic differences still exist—from language fluency and recency of immigration to educational level. Nurses must be able to deal sensitively with these differences to prevent misunderstandings and barriers to care.
“Even if [patients and providers] are from the same country or the same town, they still may view things differently,” says Julia Puebla Fortier, director of Resources for Cross Cultural Health Care in Silver Spring, Md., a national network that provides technical assistance and information on cultural competence in the health professions.
Common ethnicity may add initial comfort to the relationship between a nurse or doctor and a patient, adds Ira SenGupta, cultural competency training manager for the Cross Cultural Health Care Program in Seattle. “But we can’t make assumptions that this is the only thing that’s important,” she says.
A shared ethnic heritage does not guarantee cultural competence, SenGupta stresses. She recalls a recent-immigrant patient who was staying at a battered women’s shelter and was in need of prenatal care. SenGupta’s program matched her with a doctor who was from the same country as the patient. After the appointment, however, the woman returned to the program upset. “I don’t want to ever see her again,” she said of the doctor. Apparently, the physician had assumed that the patient only wanted an ultrasound to determine the sex of the baby. She accused the patient of planning an abortion if the baby was a girl.
“This doctor made a huge generalization,” SenGupta says. “Misunderstandings can happen when people make assumptions about others, and these assumptions can become a barrier to care.”
Like and Yet Unlike
The American Heritage Dictionary defines “culture” as “the arts, beliefs, customs, institutions and all other products of human work and thought created by a people or group at a particular time.” Thus, any culture by definition is intricately complex. Even within the same cultural minority group, differing education and literacy levels, socioeconomic status, length of residency in the United States, degree of acculturation and region of origin all have the potential to create conflict if those differences aren’t respected.
Part of the problem is that society tends to put people in categories and assume that everyone within a particular category is virtually the same. Hispanics, for instance, are often wrongly considered one homogeneous group, says Guadalupe Pacheco, special assistant to the director of the U.S. Department of Health and Human Services Office of Minority Health in Washington, D.C. But within that group are people from Mexico, Puerto Rico, Cuba and other countries. Even though Spanish is officially spoken in all of these countries, slight but significant language differences can arise. And even within the same country, colloquial terms can vary from one region to another.
Moreover, lifestyles and attitudes may vary dramatically among Hispanics who recently immigrated to the United States versus those whose families have lived here for several generations. For instance, recent arrivals to this country may be more likely to use folk medicine to treat health problems.
Among African Americans, cultural beliefs and attitudes can be vastly different for those who grew up abroad, such as in Haiti or Ethiopia, and those who were born here. “They are all of African descent, but they have different attitudes about health,” Pacheco says.
Many Haitian immigrants, for example, speak only Creole and are poorly educated. Some believe in voodoo. Haitians may use herbal teas and massage to treat health problems in the early stages, and may rely on spiritual practices to prevent illness. Yet Haitians who have recently immigrated to this country and African Americans whose families have lived here for many generations would both be categorized as “black” in the United States.
Intra-ethnic differences are also a major issue for Asian American/Pacific Islander patients. “Medical providers need to understand that we are not a monolithic group, but are very diverse in language, customs, beliefs, values and national origins,” says Kem Louie, president of the Asian American/Pacific Islander Nurses Association. “I have been asked many times to translate for Asian patients without being given information as to their national origin. Just because we are both Asian doesn’t automatically mean we speak the same language.”
Meanwhile, in India, SenGupta notes, there are 18 official languages, 1,000 unofficial languages and more than 5,000 dialects.
As for Native Americans, different traditions and practices among tribes can impact attitudes about health care. “When I care for a Native American patient, there is a common connection that happens between us,” says Sandra Littlejohn, RN, BSN, secretary of the National Alaska Native American Indian Nurses Association and administrative director of inpatient neural muscular services at Gunderson Lutheran Medical Center in La Crosse, Wis. “We are part of the same cultural group. But when it comes to certain habits or traditions, there might be different belief systems.”
Clan structures may vary, for instance. In a patrilineal tribe, a wife would go to live with her husband’s family. In a matrilineal tribe, the community link would be through the wife’s family. Health traditions also differ from tribe to tribe, including the use of herbs and the practices used for cleansing.
Taking the Time
How can minority nurses recognize and prevent potential intra-ethnic conflicts with patients before they can arise? The first step is to simply be aware that differences exist and should be respected, SenGupta believes.
Nurses also should examine the stereotypes they may have about others, Fortier says. “We all find it comfortable to think, ‘These people are like that,’ or ‘They’re just like me,’ when it comes to education and social class. It’s very easy to give in to those stereotypes.”
She agrees that being a member of the same ethnic group gives a nurse an advantage in establishing rapport with a patient. But, she warns, “If you talk down to patients, you’re going to lose that advantage.”
Cultural competency training can help nurses examine their own attitudes, Fortier continues. She recommends periodic training and re-training because people can change over time with new experiences. “I don’t think cultural competency training is a one-shot deal,” she says.
When working with clients, even those from their same cultural group, nurses must make no assumptions, believes Nilda Peragallo, DrPH, RN, FAAN, president-elect of the National Association of Hispanic Nurses and associate professor at the University of Maryland School of Nursing. “Nurses have an ethical duty to learn about clients and their needs so that they can deliver the best care,” she asserts.
This learning process can take time. “Getting to know the patient is more time-consuming than just marching in and starting to treat,” Fortier says. But the time spent figuring out who the patient really is and what he or she really needs can go a long way toward building rapport. She suggests asking patients questions such as, “When did you start thinking you had an illness?” and “Have you done anything to treat this at home?”
Littlejohn agrees that asking good open-ended questions can elicit the information nurses need to provide the right care for clients. She asks patients, “How would you normally care for that at home?” and “Are there any further needs you’d like to identify or suggest that we address in your care plan?”
Peragallo suggests asking clients where they were born and how long they have lived in the United States. Nurses should also know patients’ literacy levels so they don’t give them papers they can’t read. “You can ask these questions in a nice way,” she points out.
Because language differences can be one of the biggest barriers to quality health care, nurses should take special care when arranging for interpreters, SenGupta advises. To make patients feel more comfortable, the interpreter should be the same gender as the patient. In cases where the only interpreters available are the patient’s relatives or members of the community, they should be asked to translate everything the patient says and not to omit or add information.
“Sometimes untrained interpreters edit what patients say, especially when they think the information may not be what medical practitioners want to hear,” SenGupta explains. “But nurses need to know exactly what the patient says in order to understand and correctly meet his or her needs.”
Despite your shared cultural heritage and your best efforts to understand the patient, an intra-ethnic conflict has arisen between the two of you. For whatever reason, the patient does not feel comfortable working with you. Now what?
“As nurses, we have to take a moment to step back and reassess what’s happening in the situation,” says Littlejohn. “With Native American patients, that may involve sitting with them quietly.” Nurses may also get assistance by talking to the patient’s family members to learn what is the best way to proceed. Occasionally, resolving the conflict may even require stepping out of the situation and finding another staff member to help.
On the other hand, minority nurses can play a major role in mediating cultural conflicts between patients and doctors. “It’s important for nurses to step in at any time,” Littlejohn maintains. But, she adds, openness to discussions about cultural competency can vary widely among different workplaces. In some situations, where there is little dialogue about cultural competency, nurses must work covertly to serve their patients in a culturally sensitive way. As Littlejohn puts it, “You know what needs to be done for the patient, and you get it done.”
Meanwhile, health care organizations and providers can receive guidance from new federal standards developed by the Office of Minority Health for culturally and linguistically appropriate services (CLAS). While cultural competence has become a growing issue in the national health care agenda, until now no comprehensive standards for cultural or linguistic competence in patient care had been developed by any national group. Instead, federal health agencies, state policy-makers and national groups have addressed only pieces of the big picture. The new CLAS standards are designed to serve as guidelines to help health care professionals respond effectively to the cultural and linguistic needs of patients in today’s multiracial, multiethnic and multicultural America.
But even with federal “gold standards” and cultural competency training, there is still no easy answer for how to resolve conflicts between health care clients and providers that stem from cultural differences, or even intra-cultural differences, Peragallo believes. “For me, the most important thing is being open-minded and accepting people for who they are and where they come from,” she says.
In other words, it all comes down to treating the patient with respect and sensitivity—the very basics of nursing.
Working in health care, you have to be comfortable with change. It’s an ongoing quest to help patients, and it’s riddled with many different directions. One thing is certain, though. You can’t plateau with your studies, especially when you’re a practicing nurse.
Nursing aspirations don’t have to end with an RN degree. If you’re a natural born caregiver and feel you’ve peaked, you can reach beyond the RN and consider a career as a forensic nurse, nurse anesthetist, nurse midwife, or nurse practitioner.
Working a full-time job, staying current, and striving for more is about as easy as finding a cure for the incurable. It may seem daunting; however, with the right mindset, it’s not only possible, it’ll make your job more rewarding. Here are some noteworthy tips to a journey of success:
Focus on growth
Growth leads to desire for more. When you decide you want to grow in your nursing career, you naturally become intrinsically motivated—your desire comes from within. You begin to want more.
As a nurse, you can find growth opportunities in many places. The field is constantly growing and opportunities exist around every corner. You just have to get out of your own way and accept the fact that you need more.
Jobs in anesthetics, midwifery, forensics, along with management, are all growth opportunities afforded to nurses who have already earned an RN degree.
Opening your eyes and mind to the possibility that there’s room for improvement is hard, but re-framing your thinking helps you see opportunity.
Strengthen your writing skills
If you’re looking to go back to school or advance in your career, you have to be able to write well. If you want your ideas to be taken seriously and respected, you have to know how to convey them appropriately.
Strong writing skills will do the trick! A few writing tips you should keep in mind, especially when writing for academics are:
- Stay in the third person.
- Use a formal tone.
- Use technical vocabulary appropriately for your audience.
Strong self-study skills
In this day and age, multitasking has plagued the minds of students. They are focused on completing tasks instead of processing information. Set yourself up for success by taking the time to think about your thinking. Take an active role in trying to understand how you process information along with what methods of learning work best for you.
- Do you do better with skill and drill practice?
- Can you read and recall information easily?
- Do you need to see things in an outline?
Find your strengths and then use them to process information easily.
Growing in your nursing career can be an extremely rewarding yet challenging. Invest as much of yourself into it as possible, and you’re sure to reap both personal and professional benefits.