Nine years ago, I was so happy to have my first article published in Minority Nurse. The article was a discussion on whether or not it’s OK to be out at work as a gay person. Looking back at the changes I’ve seen over this time period, I decided to put together a few thoughts.
The county hospital where I work is rolling out some new intake questions for our electronic health record system. The impetus is to better serve our LGBTQ patients. A transgender person with residual breast tissue did not know he could still get breast cancer. An MTF person developed prostate cancer. These patients slipped through the cracks because they lived their true self but had body parts susceptible to illness that the caregiver was not aware of. By next month, we hope to have 10% of our patients properly classified using our new Sexual Orientation and Gender Identity (SOGI) questions. As the program rolls out, we will capture more and more of our population so caregivers can better serve them.
As a gay man in my 50s, I have seen great changes in my lifetime on LGBTQ issues. There was a time when just being out was a danger. But we bring some unique perspectives to our job that shouldn’t be overlooked. We know what it’s like to be the underdog. We cherish family because we worked so hard to have our families recognized. Respect for minorities come easily to us because we have suffered discrimination. Fairness in treatment under the law was not free for us or other minorities so we always strive to protect our patients’ rights. We know that being gay does not give you AIDS, but we also know what those risk factors are and we are able to educate our patients on the facts without judgement.
Now that we are rolling out a campaign to identify our patients’ unique needs regarding sexual health, reproductive issues, and mental health, we are working to destigmatize these issues in our community. Just asking these questions can be a litmus test of our own feelings. When the program was being explained in an employee meeting, there was pushback. “Our patients will be insulted.” Or, “Our patients won’t understand the terms.”
It occurred to me that we might be projecting our own feelings and, in some cases ignorance, onto our patients. Of course, there are what seem like valid issues when trying to tease this information out of patients in the geriatric clinic. My feeling is that you just throw the questions out there and you get what you get. The elderly are just as much part of the world as the young (and in between).I can’t wait to get some real world experience in asking these questions:
What is the sex on your original birth certificate?
What is your gender identity?
What is your sexual orientation?
Some explanation might be needed with some patients. Sexual identity is not your sexual orientation. Sexual identity cannot be inferred from your birth certificate. We are looking forward to the rollout but with a bit of trepidation because we are not used to asking such personal questions. But,if you want to better serve this population, you have to identify them. The FTM person who never got a breast cancer screening because his caregivers never informed him of the risk—that can be preventable with better understanding of our patients. More information is better than less.
I take away two points from the SOGI questions that excite me. The first is that caregivers are going to be more aware of the disparities in health care that can occur with our LGBTQ patients. We are charged with the care of all our patients, not just the ones that fit into neat boxes. Just being aware of the differences makes us stop to weigh implications that might have been missed in the past. The second is that by normalizing this conversation, both patients and caregivers can talk openly about a subject that was once taboo. It’s OK to be gay or lesbian, FTM, MTF, something in between, or nothing at all. We all have health care needs.
Annette Smith, a nurse and coworker with 35 years of experience, has insight into changes in practice like the new SOGI questions: “At the beginning, there is a lot of pushback. The sky is falling, the sky is falling. But after a while, the process becomes normalized and it’s not a big deal anymore. We end up wondering what all the fuss was about!”
There was a time when just talking about sexual orientation was not even considered. Now we are required to ask! This destigmatizes the whole subject. To revisit my first question: It should never be a question of whether it’s right or wrong to be out at work. It’s just a question of you being comfortable enough in your own skin to let other people know.
How often should a man get breast and cervical cancer screenings? Should a woman get screened for prostate cancer? The answer to these questions and more depends on knowing if your patient is transgender.
The Williams Institute estimated the transgender population in the United States to be 1.4 million in 2016. A recent study in Minnesota of 9th and 11th graders found nearly 3% of students identify as transgender or gender non-conforming. When it comes to health care, are we ready to meet these patients’ needs? Several cases where a transgender or gender expansive person was not properly identified or their provider simply was not aware of issues regarding transgender individuals have been in the news lately.
My county hospital is rolling out changes to our HIMS to try to capture this complete information on all of our patients, including transgender and gender expansive patients. These questions are called SOGIE, which stands for Sexual Orientation, Gender Identity, and Expression, and we ask them at intake:
What is the sex listed on your original birth certificate?
What is your gender identity?
What is your sexual orientation?
Source: Benny O’Hara, Office of LGBTQ Affairs, County of Santa Clara
Our initial goal is to capture 10% of our patient population with rolling increases as we move forward. In the hopes of meeting all of our patients’ needs we will ask these questions just one time over the patient’s lifetime. However, the patient can initiate changes at any time in the future.
Our LGBTQ patients can have health issues that are occult if we don’t have correct data. A female-to-male, or FTM, person with residual breast cancer did not know he needed breast cancer screenings. By the time it was diagnosed, the cancer was advanced. Another patient, male to female, or MTF, did not discover her prostate cancer until it metastasized to her bones.
What are the barriers to care for transgender patients? The first is the patient’s comfort with disclosing information about their sex assigned at birth and current gender identity. For a variety of reasons, transgender and gender expansive patients might not trust their caregiver or the health care system in general. A person who has transitioned has spent a great amount of personal capitol to live the life they need to live. It’s not a lifestyle change. It is the core of a person’s being.
A 16-year-old patient who has made the transition from female to male tells me, “I’m not transgender. I’m a boy.” He does not identify as transgender. Practitioners find this a common outlook in their transgender patients. Some transgender individuals may feel that they have always known their gender, and that it was society and other persons who incorrectly assigned or perpetuated a gender identity on their behalf – one that did not ring true for them. Sharing of this information with a caregiver who is not familiar with the patient might not happen if the patient is not trusting or believes the information is not germane to the situation. For a primary care provider not in the know, this creates problems with preventative care with serious consequences. The SOGIE questions start a conversation that might not otherwise have occurred.
Another barrier is on our side of the street. Are we comfortable asking a patient if they are gay and/or transgender? While rolling out our new SOGIE questions, we find push back in unlikely places. Care providers and nurses at our in-service had these objections:
“My patients will be insulted.”
“Patients of some cultures will be offended if I ask that.”
“Some patients will not understand the difference between sexual orientation and gender identity.”
“This will take too much time.”
For some, a supposed patient objection is a mirror of their own feelings. “I would be offended if someone asked me if I’m gay.” For others, cultural taboos of their own might get in the way. Are we projecting our issues onto our patients? Personally, I’m excited to see my patients’ reactions to the questions and I look forward to educating them on the meaning of the terms. It’s a valuable tool to identify health care needs and an opportunity to destigmatize a subject that might seem uncomfortable.
You can’t tell if a patient is gay, straight, or anything else just by looking. The original birth certificate does not indicate the patient’s current sexual orientation. Often, a transgender person will legally change their birth certificate to reflect their correct gender identity. We just don’t know by looking at a person or their documents what gender identity or sexual orientation they are. Health issues can’t be addressed if we don’t know.
Annette Smith, a nurse at Santa Clara Valley Medical Center in San Jose with 35 years of experience, has insight into changes in practice like the new SOGIE questions: “At the beginning, there is a lot of push-back. ‘The sky is falling! The sky is falling!’ But after a while, the process becomes normalized and it’s not a big deal. We end up wondering what all the fuss was about!”
I’m orienting as a charge nurse at a clinic. A middle-aged gay man (well, late middle age), surrounded by young women. Something odd happened that I want to share. My clinical partner, a charge nurse with 35 years of experience, pulled me into a room. “I’m going to tell you something awkward. Some of the nurses have said they feel uncomfortable when you touch them on the shoulder.”
You could have knocked me over with a feather. I honestly didn’t remember ever touching anyone and said as much. However, later that same day I actually caught myself just as I was about to touch a coworker on the shoulder and say, “Thanks for helping me with that patient.” So I had touched someone….without their permission, without thinking about it. I really had to rethink my behavior toward the opposite sex in the current climate.
Women are finding their power. Things that might have slipped by in the past are no longer going to get a pass. Frankly, I think it was a long (centuries) time coming. I hope it continues. I know it will. I’m excited to live in a time where women’s rights and female empowerment is in ascendancy.
I guess I just thought that being gay somehow made me immune from charges of sexual harassment (from women at least). This is just not the case. Harassment is in the eye of the beholder. If someone is uncomfortable with something, he or she has a right to their feelings, even if, from the other side, he/she/we may feel that nothing was done wrong (or at least intended). It’s hard to grasp, but important. Harassment is whatever someone says it is.
I admit, my feelings were hurt. I did not intend to make a coworker uncomfortable. My being gay or straight has no bearing on the issue of someone else’s feelings. I won’t argue that I didn’t mean to. I won’t say that I’m a hugger, or come from an affectionate family. Whatever my reasons for touching someone without their permission are not pertinent. All I can do is identify the behavior that caused the problem and fix it going forward.
Some might argue that the pendulum of women’s rights has swung too far. Anyone can say they feel harassed about anything. Any innocent touch, a pat on the back, is harassment and it’s just too crazy. That’s not the way to look at it. The #MeToo movement did not happen in a vacuum. It takes place in the context of an entire human history of women being treated as property and all that entails. There was a time when gay-bashing was, if not a national past-time, at least a frequent diversion, and I’ve been the victim of it several times. Gay rights didn’t happen in a vacuum, either. The broken body of Mathew Sheppard brings to mind exactly why we are fighting. Now, women are fighting.
What I’m saying is that I understand that women have a right to be seen and heard, respected, and not touched in the workplace. They have a right to pick and choose how they will be interacted with and what is appropriate. They fought for that right and continue to do so.
I’m glad that someone thought enough about me to point out something I could improve upon in my work life. I’ll keep an open mind, and my hands to myself in the future.
No one can say nursing is a stagnant profession. Even freshly minted grads can feel they are scrambling to keep up with new procedures, technologies, treatments, and processes. If you’re a nurse, you might start to wonder what skills you will need to succeed and stay current in the coming years.
There are a few qualities shared by all successful nurses. Being an excellent multitasker, having empathy, and being nearly obsessed with details never failed a nurse. No matter what your specialty, your location, or your aspirations, experts agree that a few skills in your wheelhouse will not only advance your career, but also help you satisfy your goals of being the best nurse for your patients.
“The first thing you have to have if you want to be the best nurse possible is you have to really want to do it,” says Leigh Goldstein, assistant professor of clinical nursing at the University of Texas at Austin School of Nursing. “You really have to want to be a nurse and not just bring people pills and plump pillows. To get there, you have to put in the hours and put in the study. There’s that little thing in you that tells you, ‘This is it,’” says Goldstein. “It makes learning all the other skills easier.”
LaDonna Northington, DNP, RN, BC, professor of nursing and the director of the traditional nursing program at the University of Mississippi Medical Center, agrees that nurses need a passion for the job. “This is not for the faint of heart,” she says.
Looking ahead, here are some of the essential skills nurses will need to meet job demands at any career juncture.
Develop Critical Thinking/Critical Reasoning
The best nurse thinks outside the box. Adapting to changing situations, unique patient presentations, unusual medication combinations, and a rotating team takes awareness. Assessing and evaluating the whole picture by using the critical thinking developed in school and on the job is essential to success.
“Nursing is not like working in a bank,” says Goldstein. “It’s not 9 to 5. It’s always a unique set of circumstances. You have to tailor and adjust the care you deliver based on the picture the patient is giving you.”
According to Northington, nothing in nursing is static. Nurses can’t usually just treat one patient issue—they have to determine how the patient’s diagnosis or disease has affected them across the lifespan, she says. And nurses have to consider not just the best choice for the patient and the best option for the nurse right now, but they also have to consider those things in light of the city they are in, the timing, and the resources they have at hand or that are available to them.
Make Friends with Technology
Nursing moves fast, but technological advances are sometimes even faster. While new nurses might lack years of direct patient experience, they often have essential technological familiarity. “Most nurses are probably aware that the world of electronics has just taken over,” says Barbara Vaughn, RN, BSN, BS, CCM, chief nursing officer of Baylor Medical Center in Carrollton, Texas. “The more senior nurses who didn’t grow up in the technology world tend to struggle more than nurses who grew up with that.”
With apps that allow nurses to determine medication dosages and interactions and websites that allow patients access to electronic health records, technology is an integral part of modern nursing. “Technology is changing how we practice and will change how nurses function in the future,” says Vaughn.The benefits are incredible. Instead of having to make the time-consuming drive into the ER when needed for an emergency, a specialist might now be able to save precious minutes by first examining a patient remotely with the help of monitors and even robotic devices. Nurses will have to adapt to this new way of doing things.
Nurses have to practice with technology to gain a fluent understanding, says Vaughn. Vaughn, who is studying for her PhD, says she didn’t grow up with online training as the norm, so when her new classes required online work, she wasn’t prepared. Realizing this could be a hindrance, Vaughn asked newer nurses about how to do things, and she practiced navigating the system until she became better at it.
Whether you are accessing patient records, navigating online requirements for a class, or learning a new medication scanning program, technology will improve your work day and help you take better care of your patients. In the meantime, Vaughn just recommends playing around with the computer when faced with something new. In her own department, Vaughn recalls some nurses who were especially stressed out about learning the new electronic health records system. With training and practice, they excelled. “They were later identified as superusers for their unit,” says Vaughn with a laugh.
Adapt to the Broader Picture
With all these developments comes new and greater responsibility.
“As an inpatient nurse, you used to worry about the 4 to 6 days when the patient was under your care,” says Vaughn. “Now if you are in a hospital based setting, you are going to be more involved in patient population health.” That means an inpatient nurse not only has to get the whole story of what happened before the patient arrived at the hospital, but also think about working with the care team to give specific instructions for when patients get home that will be practical.
“The more specialized medicine gets, the more fragmented health care becomes,” says Northington. Technology and that broad view can help reign that all in—and nurses need to know how the puzzle pieces fit together and where and how patients are receiving care.
“More patients will be followed in nontraditional health care settings,” says Vaughn. “Our world and the world we know is going to change,” says Vaughn of the health care industry. With more patients being followed by health care centers in easily accessed sites like Walmart and Walgreens, telemedicine is going to become more important to understand and to navigate.
Practice Effective Communication
Thirty years ago, communication about patient care was effective, but certainly not at today’s level, says Northington. “We have to communicate,” she says. “You have to ask, ‘What do you know that I don’t know that can help this patient?’ or ‘Are these therapies contradictory?’ Nurses are in that integral place to facilitate that interprofessional education and communication.”
Good communication isn’t always easy. Beth Boynton, RN, MS, author of Successful Nurse Communication, says the most effective communication is based in speaking up and in listening.
Especially in fast-paced and dynamic health care settings, the underlying interpersonal relationships can have a huge impact on how colleagues communicate and relate to each other. Nurses need to not only recognize the dynamics at play, but also learn how to work within the environment.
“We all think this is easy,” says Boynton, “but we have to recognize this is harder than meets the eye. Be patient with the learning curve.” Nurses might be assertive about speaking up for their patients’ needs, but not for their own, explains Boynton. So, as nurses look to the future, they should be mindful of not only fine-tuning their ability to speak up, but also listening to both patients and colleagues in return without judgment so everyone can work towards the best possible outcome.
“The nurse of the future has to stay committed to learning,” says Northington. “Take what the research is saying and use the best practices. Ask the questions like, ‘Why are we doing it that way?’ and ‘What can I do differently that will produce a better outcome?’”
To be the best nurse, you must stay current in the newest developments. Take the time to learn new procedures, but also recognize where your skills need updating. For example, if you know you’ll need to deal with chest tubes, don’t just assume you’ll know what to do when the time comes. Make an active effort to gain current experience.
Develop Mentoring Relationships
Every nurse needs a mentor. It doesn’t matter what your role is, how many years of experience you have, or even how many months you have been practicing. If you want to advance and learn the intangible skills needed to excel in nursing, you need to actively cultivate a mentoring relationship. Nurse mentors are often found at work, through networks, or within professional organizations.
Refine Your Personal Compass
A little bit of a thick skin will do wonders for any career nurse. “You have to defend your patient from everyone and take care of them,” says Goldstein. That means when a physician makes a call you disagree with or you overhear an unfriendly comment, you need to speak up when it matters and let it roll when it doesn’t.
And some of the personal work nurses have to do isn’t easy, including reflecting on and adjusting for any personal feelings or prejudices they have about patients in an open and honest manner. “We need to be able to take care of people no matter what their circumstances or color or what they did to get here,” says Goldstein. “You can’t treat patients differently. You need to take care of them and not make a judgment.”
Prepare for the Unexpected
You never know what your day will bring, so lots of personal reflection, discussions with others in your profession, and cultivating skills can help you when you are faced with something you’ve never had to deal with before.
“I think whether you are starting out as a new nurse or you are a seasoned nurse, nursing care is constantly changing, and being flexible to those changes is paramount,” says Princess Holt, BSN, RN, a nurse in the invasive cardiology department at Baylor Medical Center in Carrollton, Texas. It’s not easy, she says, to constantly adapt to new approaches and new practices, but nurses need to sharpen their focus. “When I get frustrated, I always go back to put myself in the mindset of my patient I am caring for or of my physician who is making this order or of the family I am taking care of to find new ways of looking at it. It grounds me and helps me understand.”
Developing all the coping skills to deal with job stress is a personal approach that nurses will cultivate as they go.
“New nurses don’t always take care of themselves and the emotional baggage you take with you,” says Goldstein. “You have to incorporate those experiences into a coping strategy that you have to develop on your own. Every nurse needs to figure out what they need to do to handle that.” And if you aren’t able to really learn how to cope, nurses must have the skills to either recognize that some kind of career shift is necessary (maybe even just moving from the ER to postpartum, suggests Goldstein) or to be open to hearing it when others recognize it.
Recognize Your Private Life Impacts Your Career
Nurses have to realize their career choice is 24/7. And while you have to balance your life and leave the hospital behind, you also have to somehow adapt to always being a nurse first. Family picnics can turn into a mini diagnosis session, neighbors might ask you to look at a child’s rash, and your private life can impact your job very directly in a way that won’t happen in other professions. “Nurses are held to a higher standard than the average citizen,” says Goldstein.
Learn Where to Learn
Yes, nurses in school learn the hands-on nursing skills like hand hygiene and infection control, says Goldstein, but, like any nursing skill, mastering them takes time.
Some hospitals have new nurse orientation programs that help new nurses acclimate to the setting, but if you don’t have that option, rely on your own observations, ask questions, and take classes to help get you up to speed. When you’re on the job, watch others to see how they incorporate things like patient safety into their routine interactions with patients. And Holt, who has worked in departments from ER to interventional radiology, says moving around builds skills. “I have seen it all,” she says, “and there is still more to see.”
Put It All Together
When nurses consider all the skills they need to succeed, some are easier to gain than others. “You need to understand what goes on behind all the mechanics,” says Northington. “It’s the knowledge behind the skills you need. They can teach nurses things. Nurses have the rest of their lives to learn things. We need nurses who know how to think, to problem solve, [and] who know when they are in over their heads to call for help. The most dangerous nurse is one who doesn’t ask a question.”
And nurses must keep moving forward and adapting even when the pace seems relentless. “We’ve come a long way,” says Northington. “And in 20 years, nursing won’t look like it looks now. Nursing is one of the best careers because it’s always evolving.”
Coping with the potential loss of one’s child is a devastating experience, and cultural influences may further hinder the opportunity for the integration of pediatric palliative care. A 2008 survey published in Pediatrics reported that over 40% of health care providers identified cultural differences as a frequently occurring barrier to adequate pediatric palliative care. Children with life-limiting illnesses deserve a cultural reassessment of how we care for them when the goal of care has changed from curative to palliative.
The concept of cultural competence and its necessity in the treatment of diverse patients
has come to the surface of the medical community within the last decade. Health care providers must demonstrate knowledge and respect of individual as well as group value systems to become effective in providing care to this population. In response to the United States becoming increasingly multicultural, the Institute of Medicine has published two reports that support the need for cross-cultural training: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare and The Future of Nursing: Leading Change, Advancing Health.
According to the American Academy of Pediatrics, the goals of pediatric palliative care are the same goals as adult palliative care, which includes providing support and care for pain, psychological and social stress, physical symptom management, and spirituality. However, the difference regarding pediatric palliative care is that the focus is specifically aimed at serving the needs of the child as well as the family. A challenge specific to pediatric palliative services is that end-of-life care for a child seems inherently unnatural in the mind of many parents and family members who often struggle to accept that nothing more can be done for a child.
The literature frequently references the underutilization of palliative care services among ethnic minorities, including African American, Latino, Native American, Russian, and Vietnamese cultures. The following attributes have been identified in the literature as a source of underutilization: a lack of the family’s familiarity with hospice and palliative care services; language barriers; religious differences; difficulties in accessing insurance; distrust of the health care services; and discomfort with introducing additional health care with professionals not of one’s ethnic or cultural background.
In 2002, the Initiative for Pediatric Palliative Care (IPPC) published recommendations for providing culturally sensitive end-of-life care that utilizes a framework that includes: improving pediatric palliative care by maximizing family involvement; understanding the influence of religion in pediatric palliative care; and understanding how culture influences lifestyle and shapes the universal experiences of illness, pain, and death across the cultural barriers. An appreciation for cultural norms and customs is critical if we are to be successful in supporting the child and the family in reducing suffering and providing comfort and support.
Cultural Influence in Decision Making As a result of the IPPC recommendations, several organizations have created reference materials and guidelines for clinicians to use. For instance, the University Of California School Of Nursing published Culture and Clinical Care, which discusses culturally competent care across 35 cultural groups. The University of Washington Medical Center (UWMC) offers Culture Clues fact sheets of useful tips when communicating with Latino, Russian, and Vietnamese cultures (among others). The journal Palliative and Supportive Care published an article in 2013 comparing cultural and religious considerations in pediatric palliative care. These resources cited the following cultural differences in end-of-life decision making:
African American • Many aspects of African American culture today reflect the culture of the general U.S. population.
• The structure in African American families is often nuclear and extended with nonrelated “family” members.
• The family may be matriarchal, although father or mother may take on the decision-making role.
Latino • Family involvement is very important in the Latino culture.
• The family-centered model of decision making is highly valued and may be more important than patient autonomy.
• The mother is typically regarded as the primary caregiver and often will make the decisions regarding care; however, when possible, Latino women will seek permission of the child’s father before a decision is made regarding continuing or discontinuing treatment.
• Often, when language becomes a barrier, the normative hierarchical family structure is waived and deferred to the family spokesperson who speaks the best English.
Native American • Given the importance of family in the Native American culture, the entire family may be included when making decisions and signing documents.
• Native Americans may also desire that information is shared with community leaders so that they can assist in the decision-making process for the child.
Russian • Health care information is shared with family members.
• The entire family makes decisions along with the patient, and the person closest to the patient often has the most influence.
• The doctor—not the nurse—is expected to share the patient’s prognosis with the patient and family, as he or she is typically regarded as the ultimate authority in all medical matters.
Vietnamese • Family has a central role.
• Decisions are often the responsibility of the eldest male, yet older women may also have significant influence.
• Traditionally, the eldest male is the family spokesman; however, the person with the best English often assumes this role.
• Removal of life support may require extensive family discussion, which places the responsibility for the decision on the entire family instead of one individual.
Importance of Faith and Religious Traditions Faith and religious traditions are held of great importance in the majority of cultures; however, it is important to note that cultural traditions are dynamic and cannot be generalized to all families. While guidelines may offer an approach to religious considerations pertaining to end-of-life care, the provider must perform an individual assessment of the family as to their beliefs and practices. The UWMC’s tip sheets and the 2013 study in Palliative and Supportive Care offer a glimpse of the cultural differences in religious traditions during end-of-life care:
African American • Death rituals for African Americans vary widely, related to the diversity in religious affiliations, geographic region, education, and economics.
• Emotional expression varies; you are likely to see a mix ranging from public displays of crying and wailing to silent and stoic behavior.
• Death is not viewed as a formal break with life, given the belief that the spirit/soul continues and may be able to interact from the next plane of existence.
• Bereaved African Americans are more likely to seek help from clergy than from health care professionals.
• Depending on their specific cultural beliefs, African Americans might involve a healer or “root worker” whose role is important in orchestrating the natural, spiritual, and relational aspects of life.
• African Americans often rely on the health care team for help with cleaning and preparation of the body.
• African Americans may refuse to stop life-prolonging treatments because of belief in divine rescue.
Latino • Prayer and ritual may be a part of the end-of-life process for the patient and family members.
• Latino families may request that they keep candles burning 24 hours a day as a way of sustaining worship. Since candles are not permissible in hospital settings, the suggestion of using electric candles is often viewed as an appreciated gesture of respecting one’s beliefs.
• The patient and the family may wish to display pictures of saints, as saints have specialized as well as general meanings for Catholics.
• Some Latino families may want to honor their deceased relative by cleansing the body.
• The last rites are often important for Latinos who are Catholic when a person is close to death. If your patient is Catholic, ask about their preference and plans for this ritual.
• Latinos often demonstrate wailing and strong emotions at the time of death, which may be considered a sign of respect.
Native American • Death rituals among the Native American tribes vary widely because they all have different religious and spiritual beliefs. It is important to assess the religious practice of the individual and follow accordingly.
• Native Americans may wish to seek traditional healers for help in restoring harmony of life.
• Herbal remedies may be used in healing ceremonies.
• The medicine man or spiritual leader leads the ritual.
• The circle is symbolic in the ritual, as in the circle of life; therefore, the family and relatives may form a circle around the patient’s bed.
• Native Americans follow the belief that the spirit of the person never dies.
• Silence is highly valued.
• Native Americans may be hesitant to sign advanced directives or other end-of-life documents because of general mistrust related to past misuse of written treaties and documents with the U.S. government.
Russian • Russians may practice different denominations. Depending on the denomination, the family may desire to have a pastor, priest, or rabbi present at the moment of death.
• The family plays a major role in supporting the sick. Usually, there is a family member present at the bedside to attend to the patient at all times.
• Russians who practice their religion may consider prayer an important and powerful healing tool.
• In the Russian culture, relatives and friends are all expected to visit the patient. They frequently bring food and may include gifts for the clinicians as a sign of respect and thanks.
• Wailing and other displays of grief may not be demonstrated as they may be reserved primarily for expression in the home (as opposed to public display).
• Often, the family may have some specific practices for washing the body after the death. It is important to ask about preferences and try to accommodate.
Vietnamese • It is important to note that there are a variety of Vietnamese cultures and religious practices. Most Vietnamese are Buddhist; however, other religious preferences include Catholic, Evangelical Protestant, and Chinese Confucianism.
• Vietnamese who practice the Buddhist faith may call a monk to give blessings. Buddhist patients and family may chant and create an altar for prayer. Vietnamese who are Catholic may ask for a priest for last rites.
• In the Vietnamese culture, white is considered the color for mourning.
• The expression of grief varies in the Vietnamese culture. Families may express grief with either a stoic response or with crying and weeping.
• Upon death, organ transplant and/or autopsies may be accepted by the Vietnamese family with very careful explanation.
• The bereavement process of the Vietnamese culture has an extremely positive impact on family health. There is intensive and extensive community involvement with frequent visits from family and friends when death first occurs and then visits are slowly weaned off over a 2- to 3-year period.
Today’s multicultural society presents health care providers with unique challenges for providing cultural care and competence to the pediatric palliative care population. This article attempts to provide insight to but a few of the cultures that we may come across in our practice. Every person is unique, and clinicians who understand their patients’ cultural values, beliefs, and practices are more likely to have positive interactions with their patients and provide culturally acceptable care.
In nursing school, we were often told by our instructors to “treat the patient as you would want to be treated.” When it comes to treating patients with a different cultural background, this mantra should translate to “treat your patients as they want to be treated instead of how you would want to be treated.”
Karen J. Smith, MSN, CRNP, NP-C, is a doctoral nursing student at Wilkes University in Wilkes-Barre, Pennsylvania. Her background includes hospice and palliative care, and she has written health-related articles for West End Happenings.
As the United States becomes more of a melting pot, encouraging and nurturing a workplace that welcomes the different cultures, ethnicities, and lifestyles of staff are paramount to optimal collaboration, productivity, and success. In health care, where diversity increasingly is exemplified among patients as well as employees, such an embrace is critical to achieving best outcomes.
Health care institutions across the country are heeding the call for inclusion. Many have implemented initiatives to not only attract diverse staff, but also to keep and engage them.
The Mayo Clinic in Rochester, Minnesota, for instance, launched the Multicultural Nurses Mayo Employee Resource Group (MNMERG) in July 2014 to recruit and retain nurses from diverse cultures and offer them professional support and networking opportunities. The MNMERG also mentors and educates Mayo’s diverse nurses and involves them in community programs.
With some 25 members, the MNMERG welcomes all Mayo staff. It meets monthly at the hospital, but this year will add quarterly dinners off site and is evaluating online technologies such as Skype and Sharepoint to “engage a 24/7 workforce,” says MNMERG cochair Deborah A. Delgado, MS, RN-BC, a nursing education specialist in psychiatry.
Mayo Employee Resource Groups (MERGs) have been an important component of Mayo’s overall diversity initiative; the goal is to have the following five core MERGs—African American, LGBTI, Hispanic, Disability, and Veterans—at Mayo’s three major clinical sites. Each MERG has an executive sponsor who is a leader at Mayo, but not a member of the group. For example, the MNMERG’s sponsor is a male cardiologist with experience in developing family/patient advisory groups. All of Mayo’s MERGs have formally chartered to align with at least one of the organization’s strategic diversity goals.
“These range from culturally competent care to inclusion and addressing health disparities,” says Sharonne N. Hayes, MD, FACC, FAHA, director of diversity and inclusion and professor of medicine at the Women’s Heart Clinic at Mayo. She notes that the groups share innovations and hold cross activities. “By that collaboration,” she says, “you get more hands to do the work obviously, but you also get a wonderful side product of some cross-cultural mentoring and some cross-cultural experience.”
While the MNMERG is in its infancy, feedback has been positive. “By being visible, by engaging, and by contributing, it just leads to retainment,” Delgado offers. “People want to stay because they’re able to use all of their gifts and talents to affect the organization’s purpose and goals.”
The Clinical Leadership Collaborative for Diversity in Nursing (CLCDN) at Massachusetts General Hospital in Boston has realized recruitment and retention success with diverse students of nursing. A scholarship and mentoring program established in 2007 by Partners HealthCare (PHC), an integrated system of which Mass General is a member, the CLCDN draws applicants from the nursing program at University of Massachusetts Boston.
Students must demonstrate leadership qualities, have cumulative general and nursing GPAs of 3.0 or higher, and must be entering their junior year of study since the CLCDN will carry them through their senior year. They link with racially and ethnically diverse nurse mentors, attend unit meetings and social and educational events, and observe nurses and nursing leaders in action. Additionally, they receive a stipend and financial support for tuition and fees with the expectation they will pursue employment at a PHC institution after graduating.
“When you’re a minority and you’re going into an environment where you might be the only diverse person on your clinical unit, as an example, it can be really challenging; it can be very lonely,“ says Gaurdia E. Banister, PhD, RN, FAAN, the PHC CLCDN liaison to UMass Boston and executive director of the hospital’s Institute for Patient Care. “We wanted to put mechanisms in place to ensure the success of our students and, certainly once they graduated, the best possible [career] alternatives,” she says.
Mass General diverse nurse leaders who have successfully navigated such waters can “provide these wonderful, wonderful pearls of wisdom and support and encouragement and listening skills,” explains Banister, and they serve as mentors, as do CLCDN graduates. Of the 54 mentors to date (32 from Mass General), some are repeats. Other statistics are just as impressive—such as PHC’s 82.6% hiring rate among the 69 graduates thus far (47.8% of whom have been employed by Mass General) and the almost 80% retention rate for these graduates.
“They love being a nurse. It’s exactly what they anticipated their career to be,” says Banister. “They are constantly promoting how positive it has been for them and that they feel like our organizations are becoming much more of a welcoming and diverse place to work.”
At the Cleveland Clinic, location-specific Diversity Councils at each of the enterprise’s community hospitals and family health centers are effectively supporting and sustaining an inclusive work environment. These employee-led councils implement action plans and sponsor activities based on strategies and goals defined by an Executive Diversity Council, all aimed to enhance employee engagement and cultural competence.
While the Executive Diversity Council works “to set the tone and the agenda,” the location-specific councils “serve as the tactical team,” explains Diana Gueits, director of diversity and inclusion. The main-campus council, for one, formed the Nursing Cultural Competence Committee and the Disability Task Force; the task force, in turn, developed the Disability Etiquette Lunch ’n Learn, a program to assist caregivers in their interaction and communication with disabled individuals that has since been taken enterprise-wide. Gueits notes the councils share and cross-pollinate ideas.
Cleveland Clinic’s chief nursing officer sits on the Executive Diversity Council, and many nurses participate in the location-specific councils with several diverse nurses serving in leadership roles (the councils overall represent a cross-section of the clinic’s workforce). Two cochairs and a cochair-elect lead each council, act as local ambassadors for diversity, engage with executive leadership, and provide feedback to the Office of Diversity and Inclusion, which facilitates the business-like, SMART-goals approach of the councils.
“This is a passion for them,” says Gueits of the cochairs, who are selected based on their experience in leading transformative teams and their commitment to diversity and inclusion. “I think that what the councils provide them is an opportunity to see, to actually be part of an initiative and be part of that process from A to Z.”
Cleveland Clinic has 21 location-specific councils, a number that is sure to increase as the enterprise expands. “That is the intention,” Gueits says, “to make sure that we embed diversity and inclusion in our commitment to all our locations and give an opportunity or platform for all our caregivers to be engaged.”
Julie Jacobs is an award-winning writer with special interest and expertise in health care, wellness, and lifestyle. Visit her at www.wynnecommunications.com.