As an academic nurse researcher from an underrepresented minority background, for years, I was plagued by a certain phenomenon: specifically, the imposter phenomenon. In 1978, psychologists Pauline Rose Clance and Suzanne Imes coined this term to describe the internal experience of “intellectual phoniness” that is prevalent in high-achieving women who, despite their academic and professional triumph, feel that they aren’t smart enough, that they have somehow deceived others to view them as successful, and that they will soon be exposed as frauds.
Of course, this phenomenon isn’t limited to women: a 2011 review article published by Jaruwan Sakulku and James Alexander suggests that 70% of all individuals experience imposter phenomenon at some points in their lives. However, in my article, I focus on how I myself experienced the imposter phenomenon as a woman with African roots within Western academia. More importantly, I share my experience to express how detrimental the imposter phenomenon is to educators in academia. Today, I feel obligated to share my story with my students through my teaching and mentoring.
What are the attributes of the imposter phenomenon? From the definition of the term, I identified
at least three destructive factors that contributed to my personal experience of it: namely, self-doubt, negative self-statements, and socialization as an African female.
An individual who sports self-doubt lacks confidence in her own capabilities and thus relies upon others to assess her accomplishments, failures, and reality. Naturally, self-doubt fuels negative self-statements that this individual utters about herself and eventually comes to believe about herself. And her negative self-statements will ultimately reinforce what her society and culture demands of women. If this individual is African like me, she will be haunted by her society’s belief that women are a weaker sex, that they should not be heard but only seen, that they are given things and will never truly earn them, and that they are meant to be taken care of by men and other authority figures in their lives.
So, how did this series of negative reasoning come to plague me? It was several weeks after starting my new position as a Sickle Cell Scholar through a grant funded by the National Institutes of Health. A staff colleague was trying to get my attention as I walked through a hallway to my office and she whispered, “Dr. Ezenwa.” I cringed and quickly turned my head around to figure out who she was addressing. Of course, it was me. We were the only two people in that space. I thought, “Wow. Dr. Ezenwa, my foot!”
As soon as this astonishment faded, I went into my office and was arrested by a severe panic at the thought of my “lies” being discovered. My body felt hot, my heart clapped with a chaotic chorus of groans, and my stomach fluttered like a butterfly rain forest. Pearls of cold sweat dripped from my palms. I felt like a deceiver, a trickster. An imposter.
Slowly, my self-doubt magnified and my anxiety about achieving success intensified. I began to question myself: Did I learn enough in my PhD program to be an independent researcher? Do I know enough to teach at the undergraduate, graduate, and PhD levels? What was I going to tell my students? What if I ruin their lives and academic careers because I teach them the wrong things and extinguish their drive for continuous learning and growth? Will they even understand a word I say to them through my African accent?
These self-doubts naturally morphed into destructive self-statements: I am not good enough. I am not smart enough. I am not worthy. Then, perhaps most devastatingly, these destructive self-statements made me feel boxed in and limited by multiple historical and social orientations forced upon women, even though I had escaped them long ago.
As an African immigrant in Western academia, I worked hard to break through multiple levels of convention. I broke through many societies’ beliefs that the proper place for a woman is at home and her role is to bear children, cook meals, and clean up messes. I broke through the pressure of growing up poor and earning the opportunity to reach greater heights without any real road map or directions. I broke through to success as a black woman who American society believes is lesser than her white counterparts thus deserves less in life. I, as an immigrant, broke through the culture shock of living and working in America and always sought peaceful resolutions to clashes in culture.
But under the spell of self-doubt and negative self-talk, I began to think that even the actuality that I’d broken out of these social constructions was all a big lie. These feelings only magnified and manifested as psychological and cognitive obstacles that cornered me into mental blocks. I soon lacked the confidence I needed to effectively teach and conduct research, as well as to see myself as successful and accomplished.
Now, I first learned about the concept of the imposter phenomenon many years ago during my graduate program. Back then, I brushed the idea aside as silly. How could individuals who paid with blood and sweat to accomplish their goals diminish their accomplishments? But after spiraling into such depths upon simply being called by my appropriate doctorate title, I realized that I was not above this sort of destructive thinking. I had to take control of this phenomenon if I was going to effectively and full-heartedly serve my students, my institutions, and, most importantly, myself.
So, how did I cope with the imposter phenomenon? There are three major strategies that I endorse and have taught my students: self-accountability, accountability with a trusted partner, and continuous self-love.
First, self-accountability: I began by recognizing that I am accountable to myself to be the best I can be in all my life’s endeavors. I am accountable for the outcomes of my actions and inactions, as well as my failures and successes. Once I accepted this fact, I engaged in bone-deep self-reflection about the imposter phenomenon that I had allowed to take up residence in me. I asked myself, “Why do you think you’re not bright enough? Why do you think you’ve fooled anyone who believes otherwise? Why do you think you’re not good enough, that you’re unworthy?”
I wrote down my thoughts on a piece of paper and waited a few days to return to it. When I saw all the questions and my initial answers written out, other realizations came to mind. I, for instance, suddenly understood that the imposter phenomenon had been creeping up on me my entire life. Growing up, everyone had told me that I was “so smart” and openly assumed that I would become a medical doctor. I had always been afraid that I might not live up to this idea of intellectual perfection that my family and friends held about me, and, even after I became an academic doctor, I felt that I was not the genius everyone believed that I was.
When I had excavated my mind of these recognitions and purged any negative ideas that imprisoned my capabilities, I reached out to my accountability partner for a meeting. I shared with her the result of my self-reflection honestly and openly and, in turn, she worked with me on enhancing my confidence. My accountability partner assisted me in three important areas: changing my mindset, developing a strategic plan of action to combat the imposter phenomenon, and constantly checking in to see if the plan was on track.
To shift my mindset, my accountability partner coached me to see the opposite side of my negative thoughts. For example, if I doubted that I was not smart enough to have accomplished the current goals in my life, she empowered me to believe that my current achievements were not handed to me for free like Halloween candy. Instead, I had to earn them through a combination of my intelligence, efforts, and wise leveraging of available resources. She assured me that I already had a long record of accomplishments, and there was no reason for that trend to stop so long as I was willing to challenge myself and do the work required.
Once this mindset shift was underway, my accountability partner helped me develop specific, time-bound goals and strategies to succeed in my current endeavors. Finally, we set a timeline with consistent, scheduled follow-up meetings to assess my progress. During these follow-ups, we reevaluated my goals and strategies, as well as adjusted my timeline as necessary.
The third and final strategy I used to combat the imposter phenomenon was practicing continuous self-love. As a woman, both in African and American society, I was socialized to care for everyone else before thinking of myself. Consequently, I was petrified to upend the status quo and focus on myself for once in my entire life; after all, I had equated self-love with selfishness.
So, to successfully exercise self-love, I had to be intentional. I worked tirelessly to reprimand myself every time I felt guilty for focusing on my needs over other obligations. I reminded myself that, when I am overflowing with love for myself, I will have enough energy to achieve my goals and dreams and also healthily give to my family, career, academics, and finances. I made sure I celebrated my successes, both big and small. Every night in front of the mirror, I stood and told myself how deserving I was of all the accomplishments I worked so hard to earn.
So, with all three strategies combined, did I beat the imposter phenomenon? That I am still a professor and a researcher in one of America’s top ten public universities is a testament to how I conquered self-doubt and negative self-statements and how I refused to allow my ancestral background and cultural identity to confine me from living in my highest potential. That I was recently inducted as a Fellow in the American Academy of Nursing is evidence that my research on health disparities in pain management in patients with sickle cell disease or cancer made a difference in peoples’ lives locally, regionally, nationally, and internationally. That I am now an entrepreneur is a manifestation of my mindset that now asserts, “You are good enough. You are smart enough. You are worthy.” So, yes, these strategies worked!
The imposter phenomenon is a monster, and the struggle to overcome it is real. Successful women have systematically been robbed of important opportunities because of our own self-doubts, negative self-statements, and our giving into social orientations that seek to confine us. But there is hope and there is help. The strategies I mentioned here, as well as with professional help from psychotherapists, can move us toward controlling the phenomenon and casting it out of our lives.
The question is, are we willing to confront the imposter monster in ourselves? Are we willing to tear down limiting beliefs about academic success, professional success, business success, financial success, and whatever else we desire? Are we willing to free ourselves from the bondage of history, cultural codes, and oppressive gender roles? Are we willing to look in the mirror and say “I am good enough, I am smart enough, I am worthy?” Are we willing to do the hard work to love and respect ourselves?
And, finally, are we willing to do the work now? Not next year, next month, next week, or tomorrow. Now.
Are you willing to take the challenge?
You may write me down in history
With your bitter, twisted lies,
You may trod me in the very dirt
But still, like dust, I’ll rise.
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.
Breast cancer is one of the most diagnosed cancers among African American women, yet research into their experiences with treatment lags behind. In particular, few studies have examined how African American women cope with fatigue, the most common side effect of treatment. To help fill the gaps, my research colleagues and I explored how fatigue affects African American women undergoing breast cancer treatment.
When it comes to breast cancer and African American women, fatigue coupled with fear are a significant part of the experience, with many African American women viewing breast cancer as an automatic death sentence. When we examine the mortality rate of breast cancer among African American women compared with women from other ethnic and racial groups, this perception is understandable. The American Cancer Society’s Breast Cancer Facts and Figures 2013–2014 report indicates that African American women had a lower breast cancer incidence rate than non-Hispanic white women; however, that same report states that African American women with breast cancer have a higher mortality rate. Many factors contribute to this racial disparity, including inadequate or lack of health insurance, screening behaviors, obesity, and a genetic component that results in more aggressive tumors.
A fatalistic view of breast cancer leads some African American women to delay follow-up visits or even avoid obtaining mammograms, which can lead to them being diagnosed at a later stage and having a worse prognosis. Then fear can turn into reality. Of all types of cancer diagnosed in African American women, breast cancer is the second leading cause of death. The five-year breast cancer survival rate for African American women was 79% compared with 92% for their white counterparts.
As health care practitioners, we can help improve these outcomes. We play a major role in educating African American women about the importance of early screening, dispelling myths associated with breast cancer, and reducing fatalism. To do this effectively, we need to understand how breast cancer affects the lives of African American women and the ways they cope with a breast cancer diagnosis, which begins at diagnosis and continues through treatment and beyond.
Recognize the Impact of Fatigue Research suggests that African American women may experience more fatigue than others with breast cancer, a condition that I’ve also observed in my own research. Rather than ordinary fatigue, they feel cancer-related fatigue—a form more distressing and severe and less likely to be relieved by rest.
For the women in our study, cancer-related fatigue began soon after their second chemotherapy treatment or midway through radiation. Symptoms worsened as treatment progressed, affecting their daily function. Their fatigue made it difficult to engage in the mental processes needed to complete simple tasks, make routine personal decisions, and balance work and health responsibilities.
Though our research involved a limited number of participants, our findings offer insights that can help health care practitioners become better prepared to treat African American women with breast cancer and address their cancer-related fatigue symptoms.
Encourage Open Communication Interactions with health care practitioners are crucial to alleviating the fatigue African American women experience during breast cancer treatment. We can ask the women to rate their level of fatigue on a scale to gauge its severity, but the best approach is to ask them to describe it, and explore the fatigue experience from a qualitative perspective. For example, how does the fatigue make them feel, and what are they doing about it?
In our study, the response was “real talk,” a common term in the African American community to describe how people speak candidly and without reservation about their feelings. The women used words like these to describe how cancer-related fatigue made them feel: disconnected, depressed, tired, burned out, weak, broken down, and washed out.
Recognizing the terminology African American women use allows health care practitioners to determine the medical implications of the words and helps build understanding and trust between patients and their nurses and doctors. It is equally important that health care practitioners convey empathy and validate what they hear, including what African American women are conveying about their fatigue symptoms. We need to acknowledge the fatigue African American women experience and have open communication with them so their symptoms can be made more tolerable and manageable.
Consider Alternative Treatments Many of the African American women in our study shared with us that the medications they were prescribed to combat fatigue were of limited benefit or made them feel worse. In contrast, choosing to exercise (such as walking) helped relieve their symptoms. Despite feeling too weak and tired to exercise, the women discussed how they pushed through the fatigue because they knew exercise would be beneficial to their health. This is consistent with past research indicating that walking has a positive effect on fatigue related to breast cancer. With permission from their physicians, the women also turned to alternative treatments, such as vitamins and supplements, herbal remedies, natural teas, and acupuncture.
Their experiences tell us that medication is only one option available to relieve fatigue. As health care practitioners, we should consider incorporating complementary therapies that may offer benefits to African American women undergoing breast cancer treatment.
Understanding the Power of Prayer and Community More than anything else, faith and prayer helped the women in our study cope with breast cancer’s overwhelming effect on their lives. Their spiritual identity made both their diagnosis and cancer-related fatigue seem more manageable.
No woman should go through breast cancer alone, and studies show that African American women rely on a wide social network that includes their church, family, friends, and faith-based, Afro-centric support groups. Joining a group of women who have similar backgrounds and experiences can help spiritually, psychologically, and emotionally. Afrocentric support groups also offer a venue where nurses and oncologists can educate women about breast cancer and fatigue related to treatment. Other health care practitioners, such as physical therapists and nutritionists, should be invited to the support groups for a more comprehensive approach.
Provide Culturally Appropriate Care Addressing racial disparities and quality of life issues for African American women with breast cancer calls for culturally appropriate care as well as effective outreach in the African American community. Health care practitioners who are part of the community and culture may better understand how to access and educate women about breast cancer screening and treatment.
Research studies support the idea that African American women are more comfortable relating their experience with breast cancer to health care practitioners who are from their same ethnic, racial, or cultural background. In a previous study I conducted, the African American women were more comfortable with breast cancer education and sharing of health tips when they heard them from African American health care practitioners and their peers. Unfortunately, the number of African American health care practitioners today is low. To provide culturally sensitive breast cancer education and care for African American women, we need to encourage more African Americans to become oncology nurses and enter related health care fields.
Breast cancer continues to take its toll on African American women, but the outlook is improving. Nurses and other health care practitioners have made significant strides in educating African American women about the disease and decreasing fatalistic views. Since 2000, screening has increased, and breast cancer is being detected earlier. Further research and better understanding of the fear, fatigue, and coping strategies of African American women with breast cancer will help us continue to build on this progress and provide better care.
Phyllis Morgan, PhD, FNP-BC, CNE, FAANP, is a nurse educator, certified family nurse practitioner, and researcher focused on African American women’s health issues. She is the coordinator for the Family Nurse Practitioner specialization at Walden University and a nurse practitioner in northern Virginia for Minute Clinic.
Shifting demographics and other market conditions have created a greater need for minority nurses, particularly in certain roles. With a growing multicultural and aging population in the United States, the need for medical case managers to serve patients of various ethnic and minority groups has significantly increased. Regulatory reform—specifically, the enactment of the Patient Protection and Affordable Care Act, which ushered in new preventable readmission requirements for hospitals, along with new models of care (e.g., patient-centered medical homes and physician-hospital organizations) and more prevalent consumer-driven health care plans—has created new opportunities for minority nurses in case management. For minority nurses whose goals are to help serve these largely underserved patient populations and advance in their careers, it is important to understand the changing health care landscape.
Let’s look first at our nation’s changing demographics. The graying of America has resulted in more Americans living longer with more age-related, chronic medical conditions, ranging from arthritis, hypertension, and heart disease to hearing impairments and cataracts. According to the National Academy on an Aging Society (NAAS), almost 100 million Americans have chronic conditions, with millions more developing chronic conditions as they age. By 2040, the NAAS estimates that the number of people in the United States with chronic conditions will increase by 50%. The cost of medical care for Americans with chronic conditions could approach $864 billion in 2040—almost double what it was in 1995. While the most common chronic conditions are the same for blacks and whites, the conditions are generally more serious among minority populations, particularly individuals with lower incomes.
Another major factor in our changing health care landscape is the higher percentage of racially and ethnically diverse individuals. An AARP Bulletin article titled “Where We Stand: New Realities in Aging” reported that minorities are expected to comprise 42% of the American population by 2030. Currently, the United States has 150 different ethnic cultures represented within its population, with over 300 different languages spoken and a wide range of cultural nuances reflected. For health care providers, this broad spectrum of cultural diversity in its patients introduces higher incidences of certain conditions, while also posing challenges relating to care and communications.
Addressing Cultural Challenges
On the disease front, we know that certain ethnic groups are more prone to certain medical conditions. Many health care providers and insurers are responding with targeted initiatives, such as: the Chinese Community Health Plan’s Diabetes Self Management: A Cultural Approach initiative to enhance diabetes knowledge and management in the Chinese population; Excellus Health Plan’s Healthy Beginnings Prenatal Care program to decrease NICU admission rates for African American teens; and Med One Medical Group’s Adherence to Hypertension Treatment and Measurement project to educate English, Arabic, and Vietnamese-speaking hypertensive patients.
Beyond the obvious language and communication barriers that can prevent quality health care delivery and optimum patient outcomes, there are cultural issues that, if mismanaged, can also interfere with providing quality health care. For example, in Latin culture, religious healing, praying to certain saints, and relying on religious symbols to address health issues are not uncommon. Patients of African descent are inclined to believe in the healing power of nature and their religion. Within Asian groups, achieving balance between yin and yang, using certain herbs and foods, and relying on acupuncture to unblock the free flow of energy (chi) are common practices. Health behaviors also vary among ethnic groups. Armenians are tolerant of county health facilities, whereas the Vietnamese regard them and the related bureaucracy associated with government facilities as degrading. They, therefore, prefer receiving care in a physicians’ office, even if higher costs are incurred.
There also are differences relating to how certain minority and ethnic groups want to hear about their medical conditions. Did you know that the majority of African Americans and European Americans believe patients should be informed of terminal illnesses, while fewer Mexican Americans and Korean Americans agree? Family values relating to health care decisions also differ among minority and ethnic groups. Within the Mexican, Filipino, Chinese, and Iranian cultures, for example, there is the belief that a patient’s family should be first informed about a loved one’s poor prognosis so they can decide whether or not the patient should be informed. Obviously, these variables and many others are important for health care professionals to understand when caring for a patient. This is an area where minority nurses of different backgrounds and cultures can be a tremendous asset to their patients and to the overall health care system. Studies have demonstrated that case managers help strengthen primary care. This is particularly true when patients have complex or multiple medical conditions—as many elderly people do—or chronic conditions such as diabetes or chronic obstructive pulmonary disease.
Combating Disparities in Health Care
It is widely known that disparities exist in the care of minority patients. While this is more pronounced in rural primary care practices, it holds true across the board. An Institute of Medicine report found that “racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when access-related factors, such as insurance status and income, are controlled.” Other studies also have explored these disparities, including Aetna’s “Breast Health Ethnic Disparity Initiative and Research Study” and Health Alliance Plan’s “Addressing Disparities in Breast Cancer Screening.” Collectively, they further make the case for minority nurse case managers to advocate for minority patients.
Related research supports the fact that, where minority case managers are in place, there is a significant improvement in patient outcomes. This was evident in a study of rural African American patients with diabetes mellitus where it was found that they were able to better control their blood sugar levels with a redesigned care management model, which incorporated nurse-led case management and structured education visits into rural primary care practices.
From Public Sector to Hospitals, Physicians’ Offices, and Entrepreneurial Settings
There is no question that, given today’s health care landscape, minority nurses have a great opportunity to help make a difference in the care of minority groups and enjoy heightened career fulfillment and potential advancement. Among the settings minority nurses can consider are:
• The public sector—serving within the Veterans Health Administration system for our veterans, many of whom are minorities, or the Indian Health System for our nation’s native American populations;
• Hospitals—helping hospitals achieve lower rates of preventable hospital readmissions, caring for minority and ethnic patients, and serving as a patient advocate and liaison with family members;
• Physicians’ offices—facilitating patient-physician communications, assuring appropriate records are communicated between treating physicians, monitoring patients’ adherence to treatment plans, and identifying any family and/or home issues that might affect a patient’s well-being;
• Financial advisors and estate planning attorneys—working with these professionals who are becoming increasingly more involved in the financial aspects of their clients’ health care and the costs associated with their care, as well as protecting their clients’ estates;
• Independent practice—working for a case management firm or establishing your own practice.
Independent practices present an opportunity for minority nurses to shape their own destiny and financial reward. Through one’s own practice, a minority nurse can focus more fully on his or her patients’ well-being without the over-emphasis on cost containment we see in many other practice settings, especially hospitals. These nurses can decide that they want to specifically dedicate their practice to a certain minority and/or ethnic group. They can establish a truly patient-centered care management business model, performing health risk assessments, providing health coaching, disease education and management, assisting with patient transitions of care, coordinating health care resources on behalf of their patients, reviewing hospital bills, helping patients assemble their health records, and providing end-of-life care coordination.
Based on a 2013 survey by the National Council of State Boards of Nursing and The Forum of State Nursing Workforce Centers, nurses from minority backgrounds represent 17% of the registered nurse (RN) workforce. Currently, the RN population consists of 83% white/Caucasian, 6% African American, 6% Asian, 3% Hispanic/Latino, 1% American Indian/Alaska Native, 1% Native Hawaiian/Pacific Islander, and 1% other. Given the increasing shortage of nurses, combined with the growing demand based on our shifting demographics, it appears that the time has never been better for minority nurses, while fewer in number, to take center stage in case management.
Catherine M. Mullahy, RN, BS, CRRN, CCM, is president of Mullahy & Associates www.mullahyassociates.com, and author of The Case Manager’s Handbook, Fifth Edition.
The Regis College Haiti Project (RCHP) is an international partnership between Regis College School of Nursing, Science, and Health Professions, the University of Haiti, and Haiti’s Ministry of Health. In February 2014, with completion of a three-year program, 12 nursing faculty members were awarded Master of Science in Nursing (MSN) degrees from the University of Haiti. Through the commitment of Regis College, three cohorts over the course of seven years will obtain their master’s degree and provide sustainable nursing education advancement to all nurses in Haiti.
With this strategic plan, the RCHP enables us to build a dynamic and mutually beneficial, sustainable nursing program where faculty members in Haiti will be qualified to teach as well as produce educated nurses to serve in primary care areas and assume leadership positions with colleges, hospitals, and other health care organizations. Nurses are the key component in a health care system, and providing sustainable nursing education to a developing country is the cornerstone to the betterment of health care delivery.
Building a Relationship with Haiti
The initial stage of this international relationship began in 2007 when the president and several faculty from Regis College travelled to Haiti to meet with the ministry of health and nursing leaders to determine how they could establish a collaborative agreement to improve nursing in Haiti. A primary goal in the strategic plan of the college, among many objectives, is to establish an international footprint through interdisciplinary academic programs, the spirit of collaboration, and student-centered values. The vision statement of the college inspires all to work within its multicultural community and to be actively engaged as leaders and ambassadors of social change.
To develop a strategy, nursing leaders from both Haiti and Regis College consulted and discussed schedules, time commitment, action plans, and long-term sustainability. The mission of the RCHP is incorporated in developing an international nursing partnership. Through this vision of partnership is the goal to improve the health and well-being of the people of Haiti by elevating the level of nursing education and the sustainability of advanced nursing practice.
Project Goal
The RCHP is designed for the registered nurse in Haiti to earn both the baccalaureate and the master’s degree. Its purpose is to prepare nursing educators and nursing leaders to assume a guiding role in the effort to address Haiti’s pressing health care needs. Nurse administrators with advanced nursing education have a unique perspective in the assessment of health disparities and challenges faced in providing care to a vulnerable population. After completion of this program, they will be able to collaborate with local professionals; assist in the creation of sustainable, community-focused programs; practice collaboratively as members of interdisciplinary teams; and deliver population-focused care while reflecting on the impact of poverty and socioeconomic factors.
Specifically, this project seeks to address the acute nursing shortage in Haiti and overall advance the level of nursing education in the country. A 2003 study published in The Journal of the American Medical Association concluded that nurses prepared at the baccalaureate level or higher have significantly better patient outcomes. Partnering with our Haitian neighbors provides a new and expanded role for nurses in a developing country. Upon graduation with a MSN, this first cohort of Haitian faculty will lead the institutionalization of the master’s program for all future Haitian nursing faculty.
Currently, the public nursing schools prepare three-year diploma graduates with their focus on hospital-based care. The objective of this program is to educate Haitian nursing faculty, who can then provide baccalaureate education to all nurses in Haiti and be role models in nursing leadership.
In order to produce a new generation of nursing leaders in Haiti, capacity building is necessary. This entails a society enhancing their abilities to “perform core functions, solve problems, define and achieve objectives; and understand and deal with their development needs in a broad context and in a sustainable manner,” as described in the International Institute for Educational Planning’s Guidebook for Planning Education in Emergencies and Reconstruction. The strategies needed to accomplish this mission include the following: enhancing professional development through curriculum building; analyzing the relationship between theory, practice, and evidence-based research; synthesizing the organizational structure of nursing leadership; and promoting innovative educational methodologies.
Project Planning and Implementation
The RCHP is committed to educating three cohorts of Haitian nursing faculty over the course of seven years, with two overlapping cohorts in the summer of the third year, which would serve as transition and mentorship periods. The sidebar outlines the three years of the program and the required coursework for each cohort (see page 42).
The program began in the summer of 2011 with 12 Haitian nurse faculty from nursing schools across Haiti coming to Regis College in Weston, Massachusetts, for a six-week intensive program of study where orientation and tutorials on computer systems were provided as well as weekly graduate student dinner seminars. Each Haitian nurse faculty was paired with a Regis College nursing faculty member who remained the nurse’s mentor throughout the course of the program. The match of mentors was based on professional experiences and shared interests. The mentors served as academic and professional advisors as well as social support, and they offered guidance throughout the academic year.
When the Haitian nurses were at Regis College during summer sessions, there were opportunities for in-person interactions between mentors and mentees. In addition, the Haitian faculty had the opportunity to shadow nurses at several of the large metropolitan hospitals where they observed cutting-edge technology in both medicine and nursing. During the fall and spring semesters, the mentors and mentees maintained contact via e-mail, Facebook, Adobe Connect, and Skype, and they received technical support through Regis.
During the first year of the program, Regis College nursing faculty traveled to Haiti, where they taught in an intensive five-day format addressing trends affecting community health nursing—specifically, societal and population shifts in the different regions of Haiti following the 2010 earthquake. Morbidity and mortality concerns were also addressed in conjunction with the changes and evidence of population shifts into the cities secondary to the aftermath of the earthquake and the environmental changes. In conjunction with the Regis College philosophy of nursing—which identifies the four central concepts of the nursing discipline as person, environment, health, and nursing—each of the 12 Haitian nursing faculty identified a specific health problem endemic to their community. This was followed by identifying priorities, establishing goals, and determining interventions based on the central tenets of the philosophy. In order for the Haitian faculty to analyze a community health problem comprehensively, we introduced the epidemiologic triangle, the traditional model for infectious disease addressing the external agent or the cause of the health problem, the susceptible host identified in the community, and the environment in which the host and agent came together leading to a specific problem or outcome.
During the second year of the program, the 12 Haitian nursing faculty returned to the campus for a five-week intensive session of clinical and classroom learning over the summer of 2012. The following spring, Regis faculty traveled to Haiti for a one-week intensive training supplemented by online learning.
At the start of the third year, the 12 Haitian nursing faculty returned to the campus in the summer of 2013, where they took part in another five-week intensive session of clinical and classroom learning. Simultaneously, the 12 Haitian nursing faculty who were selected for the second cohort also arrived to the Regis campus for the first time to begin their first year of the program. With the help of Regis nursing faculty, the first cohort became the mentors for the incoming cohort and worked together to teach two out of the four courses taken by the second cohort. The first cohort continued to take two courses alongside the second one.
Conceptual Framework
In February 2014, Regis nursing faculty returned to Haiti during the mentorship period. The first cohort of Haitian nurses assumed the role of educators as they taught nursing theory, nursing leadership, and community health to the second cohort of nurses. With awareness of the shift away from traditional hospital-based care and movement toward the community, they introduced new models of care supported through collaboration in practice and education.
An example presented by the second cohort was Roy’s Adaptation Model, as it was reconceptualized and expanded in order to provide a framework for the delivery of community-based nursing. Using this theoretical framework, they encompassed population-based assessments that related to the physical, psychological, and social integrity of their community. Through this model, they identified the central concepts of the discipline of nursing with the understanding that every person has inherent dignity and worth as well as a right to receive comprehensive, compassionate health care. They viewed the person in the community as a unique biopsychosocial, cultural, and spiritual being who continuously interacts with the environment.
Using Roy’s Adaptation Model as an adjunct in the coordination of community health in Haiti offered the nurses an organized approach in the assessment of their community, incorporating the philosophic components of person, environment, health, and nursing. Through discussion of the physical integrity, their view was broadened as they identified topics incorporating nutrition, the environment, available resources, and government regulation. In discussion of the biopsychosocial characteristics, identifiers such as age distribution, gender, education, and economics were discussed.
The social integrity of the community presented another perspective in assessment of a specific community by focusing on vital statistics, such as births, deaths, prevalence of communicable and chronic disease, leading causes of mortality, and health resources. Using these guidelines in data analysis assisted with community care planning by identifying a community diagnosis, an awareness of the problem, community motivation, and realistic interventions to resolve the problem.
Challenges and Outcomes
A course challenge in our collaborative efforts of educating our Haitian colleagues was the language difference. This was addressed using a bilingual educational platform. Educational material using PowerPoint was introduced with French translation. In addition, an in-class translator was present to translate lectures, questions, and small group discussions. Through the use of Adobe Connect, Moodle, an internet connection, and e-mail, we were able to provide effective international collaboration. This also allowed rigorous evaluation that strengthened the educational models used in promoting effective community health systems for the Haitian nursing faculty. The inability to access French-translated textbooks on community health nursing and nursing theory posed another challenge, but we were able to address it by utilizing a French publishing company.
Through enhancement of scholarship and curriculum development, the new graduates will increase community awareness as well as strengthen and analyze how the environment and personal health behaviors are interrelated. Being part of the community afforded the Haitian nursing faculty the opportunity to influence and motivate others. Their understanding of Haitian lifestyle, culture, and social skills provided them practice opportunities and professional collaboration in addition to critical analysis within the community. It allowed them to be part of effective community action by contributing to the resolution of a problem.
The outcome of the first cohort came to fruition in February 2014 when the University of Haiti awarded master’s degrees to all 12 faculty members representing nursing schools across Haiti from Gonaïves, Les Cayes, Port-Au-Prince, Jérémie, Cap-Haïtien, and University of Notre Dame d’Haiti. Subsequent to achieving the master’s degree, many of the first cohorts have assumed leadership roles in their schools of nursing. One in particular was appointed dean of her nursing school, while others are taking an active role participating in professional conferences in order to enhance the international influence of nurses. Others are enhancing course content through curriculum development and are reaching out to community leaders in order to develop collaborative relationships with interdisciplinary teams. In addition, membership in professional associations has offered the Haitian nurses recognition of their expertise through certification—providing them an opportunity to make a difference and lobby to influence laws affecting nursing.
In providing new and expanded skills in nursing education, this international partnership will help ensure that nursing education in Haiti continues to progress throughout the 21st century with the use of critical thinking, problem solving, and evidence-based practice. Through collaboration, the Haitian nurses have the capacity to build sustainable nursing programs that are beneficial and dynamic for the Haitian society.
