President Obama signed the historic Patient Protection and Affordable Care Act into law on March 23, 2010, and its first changes went into effect on July 1 of the same year. But signing that bill was just the beginning of a passionate national health care debate. Even one year later, the dust is far from settling.
One of the most politically divisive issues in the United States’ history, the Patient Protection and Affordable Care Act has been at the forefront of public and Congressional discourse practically from the moment it was written. Reforming the health care laws of the early 20th century has been a topic of discussion since the 1970s.
Yet, revisiting the Patient Protection and Affordable Care Act today is really just rehashing what was signed into law a year ago. Not much has actually changed, though those opposing the Act in the deeply divided Congress say it will change, and soon.
“Reforms under the Affordable Care Act have brought an end to some of the worst abuses of the insurance industry,” says the White House on its health care reform website, www.healthcare.gov.
Some of the more prominent facets of the reform include ending lifetime and some annual limits on care, allowing adults under age 26 to stay on their parents’ insurance plans, and forbidding insurance agents from denying care to children with preexisting conditions.
Regarding Medicare, almost 48 million of those receiving aid are eligible for free preventive care, including mammograms and colonoscopies, among other Medicare-specific reforms like prescription drug discounts.
The Act also takes into special consideration the disparities surrounding health care and minority populations. Minority Nursefrequently covers the lack of access to care and disproportionate incidences of disease, and the Patient Protection and Affordable Care Act outlines several initiatives to combat those inequalities.
Especially pertinent to low-income patients, the Act calls for subsidized preventive health care services like annual exams, immunizations, and cancer screenings for those falling into certain eligibility groups. It also invests in cultural competency and language training, chronic condition management teams, and community clinics, with a goal of doubling the number of patients those clinics can serve. The Act also provides funds for home care visits for pregnant women and new mothers, in an effort to stem the low birth weight and infant mortality epidemic affecting minorities.
Finally, by 2014, the Act will establish State-based Health Insurance Exchanges that will create a competitive health insurance marketplace and “guarantee that all people have a choice for quality, affordable health insurance even if a job loss, job switch, move, or illness occurs,” according to the U.S. Department of Health & Human Services.
Multiple parties have already questioned the Patient Protection and Affordable Care Act’s constitutionality, saying Congress does not have the power to require individuals to buy health insurance. The Obama administration has countered these claims, pointing to Congress’s Constitutional right to regulate interstate economic activity. The crux of the Act is fostering those State-based Health Insurance Exchanges, giving states flexibility in their implementation and giving individuals a choice that spans state borders. Surveys conducted by third parties, such as the Harvard School of Public Health, showed many Americans support the Act and many of its provisions, and that there is no swell of people hoping to have it repealed. Obama’s Congressional Budget Office also estimates the Act will eventually save money, reducing the deficit by $138 billion.
The White House, for its part, has tried to tout those functions of the Act that are already helping people, like the Medicare discounts and continued insurance coverage for young adults. However, though millions have already benefited from the law, most of the country has yet to feel its effects, making the continuation of these costly and sweeping changes seem pointless. The Act calls for more drastic health care overhauls through 2014, including many of the provisions directed toward reducing health disparities, but for the uninsured and underinsured, that can be a long wait.
Of course, speeding up the implementation of the Act isn’t an option, but voting during the 2012 election is. Nurses can support these changes (or refute them) with their vote. In the meantime, nurses can educate themselves, as the repercussions of the Act—whether it endures or is repealed—will be felt in communities and clinics, in juggernaut HMOs and small businesses, for years to come.
Because immigrants from Asian countries with large Buddhist populations are a rapidly growing minority group in the U.S., it’s important for nurses to understand Buddhist patients’ beliefs about health, illness and food.
The love of nature and maximum enjoyment of what nature provides us is necessary in order to live a truly natural life. This is the main belief in many Asian cultures, such as those of China, Japan, Taiwan, Korea, Tibet, Sri Lanka, Thailand, India and the Philippines. While Christianity is the dominant religion in many of these countries, there are also significant numbers of Buddhists, along with Muslims, Hindus and atheists.
In the Buddhist faith, life revolves around nature with its two opposing energy systems, known in Chinese philosophy as yin and yang energy. Examples of these opposing energy forces, which are cyclical, include heat/cold, light/darkness, good/evil and sickness/health. Although a simple illness, such as a cold or flu, may be considered an imbalance of yin and yang energy, many Buddhists-though not all-believe that the best way to live a healthy life is to be a vegetarian.
The Buddhist tradition of vegetarianism has gained a great deal of popularity around the globe, as both a diet and a way of life. In the United States alone, according to World Animal Foundation there are 9.7 million vegetarians. At the same time, in certain Asian cultures there has been a strong movement away from the traditional strict vegetarian diet as a result of these countries’ exposure to Islam and Christianity.
Part of being a culturally competent health care professional is being careful not to make blanket generalizations about patients from unfamiliar cultures-such as assuming that if a patient is an immigrant from an Asian country, he must be a Buddhist. Even if it is known for a fact that the patient’s religion is Buddhism, this does not necessarily mean that he or she strictly follows all Buddhist religious practices to the letter. It is vitally important for nurses to initiate dialogue with patients and their families in order to determine what, if any, cultural/religious needs and dietary restrictions must be accommodated to ensure the best possible healing process for the patient.
Understanding Buddhist Beliefs
The Buddha was born in what is now Nepal and founded Buddhism in India during the sixth century B.C. After Buddha’s death, his followers considered him a divine entity with the ability to lead them to Heaven.
This is a faith of supreme optimism that teaches self-control as a means to search for true happiness. Buddhists practice yoga and meditation as a means to reach spiritual emancipation or true liberation. Through mastering self-control, a Buddhist can reach full potential toward a journey of self-improvement during this life in order to achieve reincarnation, or rebirth after life. The rebirth process requires a desirable state of freedom or purity from primitive human desires and wishes.
The Buddhist code of morality is set forth in the Five Moral Precepts, which are:
1. Do not kill or harm living things.
2. Do not steal.
3. Do not engage in sexual misconduct.
4. Do not lie.
5. Do not consume intoxicants such as alcohol, tobacco or mind-altering drugs.
Buddhists believe that being careful in selecting the food one eats correlates with the amount of light in one’s body and the degree of power necessary to climb up the spiritual ladder-i.e., to reach the desirable state of relaxation and of being sincere to oneself and others. By following this path, one’s soul reaches harmony, the desirable spiritual status and/or the power of virtue necessary to attain the reincarnation process.
Buddhist Dietary Practices
In the teachings of Buddha, this concept of making the right food choices for spiritual enlightenment is exemplified by the “Five Contemplations While Eating.” Essentially, this means that Buddhists are exercising a special force related to “stopping and thinking” about the food they are eating.
(Interestingly, it is believed that the Buddha himself actually died from food poisoning.) A Buddhist asks himself these five basic but essential questions:
1. What food is this? = The origin of the food and how it reached me.
2. Where does it come from? = The amount of work necessary to grow the food, prepare it, cook it and bring it to the table.
3. Why am I eating it? = Do I deserve this food or not? Am I worthy of it?
4. When should I eat and benefit from this food? = Food is a necessity and a healing agent because I am subjected to illness without food.
5. How should I eat it? = Food is only received and eaten for the purpose of realizing the proper way to reach enlightenment.
A Buddhist GlossaryVegetarianism: A diet that includes no meat. In the Buddhist religion, eating a vegetarian diet is a natural and logical ramification of the moral precept against the taking of life. Veganism: A philosophy of life that should be thought of as entirely separate from vegetarianism. It is concerned with an entire lifestyle rather than just a dietary regime. Veganism prohibits not only the eating of animals, animal products and their derivatives-including milk, cheese and honey-but also the use of animal furs, leathers, skins, etc. Vegans believe these products-and even their by-products-must be avoided at both the physical and mental levels to ensure true liberation that facilitates the attaining of enlightenment.Ahimsa: The act of not killing or harming. It refers to the compassionate, non-violent treatment of living things and the acknowledgment of all sentient creatures’ right to live and be reborn. Practicing ahimsa will keep the Buddhist on the right spiritual path and enforces “a better life and better health.”Karma: A sort of spiritual bank account that is accumu-lated through one’s actions in life. Good karma occurs for those who follow Buddhism’s moral precepts; it will lead to being reborn as a higher being, such as a god or wealthy human. Bad karma, which can result from forbidden acts such as killing living things, can cause one to be reborn as a lesser being, such as an animal, insect or demon. Once you pay off your karmic “debts,” you can be reborn as human.
Buddhists who are strict adherents to their faith depend not only on these Five Contemplations but also on the Five Moral Precepts to determine which foods are appropriate to consume and which are considered forbidden. In general, Buddhism prohibits the eating of any and all meat, because (1) the killing of animals violates the First Moral Precept and (2) meat is considered an intoxicant to the body, which violates the Fifth Moral Precept.
According to the Fifth Precept, consuming any type of intoxicants will reflect negatively on a Buddhist’s life and afterlife in the following ways:
o Effects on Self: It will distort and cloud one’s samadhi-i.e, it will hinder one’s judgment and decrease proper concentration necessary for meditation, which is the path to enlightenment.
o Effects on Others: It will increase one’s susceptibility to commit crimes and do wrong to others, which means loss of the desirable self-control.
o Religious/Spiritual Effects: It can cause bad karma (see Glossary) that harms other sentient beings and later on will haunt the original being.
Buddhists believe that whoever lives only for pleasure loses his soul’s harmony and the power of virtue. According to the “no killing” precept, whoever kills animals or eats meat will lose the “purity of both body and mind”-i.e., one gets all mixed up with the meat one eats and loses purity, clarity and the power of self-control. Buddhists also believe that causing the suffering of living creatures just to satisfy our taste buds is not a justifiable reason to eat meat. In Buddhists’ eyes, hunger is the minimal expression of compassion that can be offered and becoming a vegetarian is a choice-i.e., choosing not to kill animals (out of kindness) and not to eat them (out of compassion).
In addition to the physical suffering of animals, Buddhists believe that eating meat also causes another type of suffering: bad karma. Killing a sentient being forces it to begin a painful process of rebirth. Since Buddhists believe it is possible for animals to attain enlightenment, killing them deprives them of that chance. Eating a vegetarian diet helps ensure that the cycle of karmic retribution will be purified:
If you don’t eat animals, they won’t eat you. If you don’t kill them, they won’t kill you.
Other foods that may fall into the “forbidden” category include “the Five Pungent Spices.” This refers to onions, scallions, chives, garlic, etc. Traditionally, Buddhists have believed that a person who eats these foods will suffer the following ill effects:
His blood and flesh will be rejected by the gods, and the heavens will distance themselves far from him.
His breath is always foul; therefore, all gods and saints will reject him.
If eaten cooked, these foods will arouse lust and cause explosive temper.
If eaten raw, they will increase one’s anger and cause bad body odor that will not please the gods but will stimulate interested “hungry ghosts” who will hover around and kiss one’s lips. Being near ghosts is believed to hinder one’s enlightenment.
Today, however, many vegetarians around the world, including some Buddhists, may eat the Five Pungent Spices without reservation. For Buddhists, this depends on such factors as the person’s degree of adherence to their faith, whether they are practicing Buddhism along with other faiths, and their geographic location.
Health Benefits of the Buddhist Diet
Examples of permitted foods that are staples of the traditional Buddhist diet in many Asian cultures include:
1. Boiled or stir-fried noodles flavored with aromatic spices. Raw or cooked vegetables, seaweed and home-prepared dried food items can also be added.
2. Rice, which can be cooked and flavored in many different ways-e.g., salty, sweet, neutral, sticky, colored or mixed with vegetables.
3. Soy sauce is an essential tasty ingredient that is added to almost every dish, in much the same way as Americans flavor many of their foods with butter and/or salt.
4. Sesame oil is also used heavily in preparing food. Unlike soy sauce, it contains no sodium.
5. Buddhists who are not strict vegetarians will eat fish on an almost daily basis and/or will add it to many of their meals.
6. Herbal tea is a popular and healing drink that originates from various types of tea plants.
For centuries Buddhists have believed that when meat is eaten it accumulates in the body, turning into harmful toxins. Today, modern medicine seems to be proving them right. A number of recent scientific studies have discovered a high incidence of cancer within populations that consume large amounts of meat. Other negative health consequences that have been linked with eating meat include arterial sclerosis, heart disease, high blood pressure, encephalitis, stroke, gallstones and cirrhosis of the liver. All of these conditions are directly related to consuming fat and cholesterol.
According to the Encyclopaedia Britannica, meat does in fact contain wastes and toxins, such as uric acid, that have negative effects on blood and body tissues. In contrast, vegetable proteins obtained from nuts, beans and legumes are decidedly healthier and safer. Furthermore, meat, meat products, poultry and seafood all spoil easily within a few hours, but most vegetables stay fresh for several days. Although beans may become rancid relatively quickly, the deterioration is much easier to detect and recognize compared to spoilage in meat, which may not always be detectable by smell or taste.
Cultural Competence Tips for Nurses
When caring for patients who are followers of the Buddhist religion, nurses need to understand that the patient’s main goal is to bring back the body’s yin/yang equilibrium that was disrupted because of illness. It is helpful to first discuss the patient’s illness and care plan in relation to this concept before volunteering a medical or patho-physiological explanation. Because of the supreme importance of nature in Buddhists’ lives, a culturally sensitive medical team will want to prescribe both herbal medicine and pharmaceutical medications, if appropriate. Remember, in these patients’ eyes the goal is not curing but rather maintaining peace of body and mind that will ensure the rebirth process after death.
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In terms of dietary assessments, the first step is obviously to find out whether the patient is a vegetarian, how strict or liberal he/she is in following the traditional vegetarian diet and whether there are any other dietary restrictions the patient must observe. The risk of vitamin B12 deficiency among pure vegetarians can be managed by increasing their daily intake of the different types of vegetable proteins.
Buddhist patients staying in a hospital that only serves American-style food may appreciate being provided with a bottle of soy sauce that they can keep in their room to flavor their meals in the way they are accustomed to. The rule of thumb is: When in doubt, ask the patient what he or she would prefer. Be sure to check the labels on different soy sauce products for their sodium content, which can range from 300 grams to as much as 1,080 grams.
Gihan ElGindy, MSN, RN, is an educator and independent consultant on health, nursing, cultural competence, education and business entrepreneurship issues. She is the executive director of the Transcultural Education Center (TEC) in McLean, Virginia. For more information about TEC, visit www.tecenter.org.
As a Certified Registered Nurse Anesthetist (CRNA), I have to interface and plan anesthetics for this diverse group of patients. Not only must CRNAs take into consideration age, weight, assessment of health issues, airway and anesthetic plan but also the linguistic and cultural issues that influence each patient’s directed care management.
Removing Language Barriers
After checking the anesthesia machine and preparing emergency and anesthetic drugs, nurse anesthetists or nurse anesthesia students must conduct an interview and assessment of their patients before moving them to the operating room. During the interview, they may find there is a language barrier. There will be patients where English is a second language and/or patients with limited English proficiency. It is imperative that each patient, regardless of the language barrier, is fully informed regarding his or her anesthesia.
Nurse anesthetists should always avoid using patients’ bilingual children, family members and friends as translators. Using these familiar people as interpreters seems like a quick fix, but they dilute the interaction at best or misinterpret in the worse case scenario. Patient privacy should be foremost in securing anesthesia consent.
The best form of communication with a patient with limited English proficiency is the Language Line Service that can be found in most hospitals. After completing the necessary preparations for anesthetizing the patient, nurse anesthesia providers should locate the nearest Language Line telephone.
Not every patient room has this special telephone, and it is important to physically move it from the nursing station into the room if necessary. For example, when I was the Chief Nurse Anesthetist at South Jersey Healthcare System, if a Mexican immigrant patient with no English capability was in labor, I would ask the charge nurse for the Language Line telephone, which was retrieved from the nurse’s station and taken into the patient’s room.
This special telephone has two receivers. Only the anesthesia provider and the patient are on the telephone, simultaneously speaking with a trained interpreter. The anesthesia provider gives the operator the account number and requests the preferred language from the patient. The Language Line translates over 180 languages.
When interviewing patients via the Language Line telephone, it is best to ask short questions in terms of allergies, last meal, previous surgeries and anesthesia, health issues and the preferred anesthetic plan. Nurse anesthetists should make sure that the last question they ask their patient via translator is “Do you have any questions regarding your anesthesia?”
The Language Line operator identifies his or herself as a number, not by his or her own name. It is important to capture the identifier number on the anesthesia consent form to ensure that the Language Line was the best form of communication used prior to scheduled or emergency surgery.
The anesthesia consent at South Jersey Healthcare System had an English and Spanish version. The patient would sign the Spanish side, where the Language Line operator’s number was clearly written, along with the anesthesia provider’s name, the signature of a witness like a registered nurse and the date and time.
Cultural Issues
I have observed several cultural trends in my years as a nurse anesthetist. For example, the Hispanic/Latino patient typically has a great deal of supportive family members who will come to visit or accompany the patient. This does not necessarily affect my work; however, some culture-specific customs do.
One cultural issue I have encountered concerns the Asian patient population, particularly aged patients. A cultural norm that needs to be acknowledged by anesthesia providers is the “coining” of Southeast Asian patients. This practice involves applying hot oil to the back and torso, then rubbing a coin or the edge of a spoon on the skin until circular or linear marks are embedded. Anesthesia providers typically auscultate patients’ lungs and/or perform regional anesthesia. CRNAs may see these marks on a patient’s back when giving spinal epidurals and not know what they are. It is important to recognize this practice before administering anesthesia and not misinterpret it as elder abuse or any other form of abuse.
Another cultural issue for nurse anesthetists is taking care of Muslim and Orthodox Jewish patients, especially women. These groups are similar in their treatment of married women, and couples tend to be concerned with female patients’ exposure to males in the operating room. Muslim and Orthodox Jewish patients may insist on wearing the hijab or a simple scarf or wig while in public. They will often ask for only female providers in the operating room, if staffing permits. It is important to relay to these patients and their husbands that their modesty as a patient will remain intact as much as possible, including covering windows in the operating room. CRNAs must communicate with male surgeons not to enter the room until the patient has been properly identified, put to sleep by a female CRNA and draped by the OR technician. Only after the surgeon exits should window coverings be removed. The patient should be covered with blankets as she is transferred to the PACU.
Lastly, another cultural group of patients that should be acknowledged are women from Africa, the Middle East and other regions practicing female genital mutilation (FGM). According to the World Health Organization, 100–140 million girls and women have undergone the cultural indoctrination of FGM. Typically, girls age 7–10 will go through this process, where the external genitalia are partially or totally removed, often with crude instruments (not sterilized) and under no anesthesia. The repercussions are wide, from infection to vaginal birthing issues to psychological problems as adults. Women from these cultures who reside in the United States will require anesthesia services for cesarean sections and major genital reconstructive surgery. Nurse anesthetists should be aware of this practice and how it will impact their work.
Again, with the changing demographics of the United States, our patient population will dictate new ways of approaching their anesthetic plan. We must treat each person regardless of ethnicity, language barrier or imposed societal cultural norm in the same manner as we do with our family members, neighbors and friends… with the utmost respect and dedication to our anesthetic practice.
The road back from addiction is arduous—for those in the grips of the addiction, of course, but also for the people around them, including their health care providers. Though prescribed manners of treatment exist, every journey to recovery is unique, every substance abuser takes his or her own path. Why should it matter, then, if nurses and other health care practitioners take into consideration the patient’s culture and background? In short, because understanding patients on a more personal level through familiarity with their cultural and social mores can lead to more effective substance abuse treatment.
Panelists Thelma Chandler Director of Clinical Services, Centerstone Donald Degner, M.A. Substance Abuse Services and Randolph County Clinic Coordinator, Centerstone Erick Guerrero, Ph.D., M.A., B.A. Assistant Professor, University of Southern California; Licensed Clinical Therapist Lolita Roland, R.N. Case Manager, Outpatient Addictions Service, Cambridge Health Alliance Andrew Spanswick, M.S.W. CEO and Co-founder, KLEAN Treatment Center
“The general argument is that through cultural competence, providers can enhance the therapeutic alliance, which may lead to high client engagement,” says Erick Guerrero, Ph.D., M.A., B.A., an assistant professor at the University of Southern California and licensed clinical therapist. “Research supports the notion that deep and effective cross-cultural training, translation of material, and use of translators are associated with better engagement outcomes in [substance abuse treatment].”
The solutions start simple, such as cross-cultural education for all providers, particularly managers and administrators, perhaps provided on an annual basis. A straightforward adjustment toward culturally congruent care is providing adequate translation services. For example, it’s hard to refute the instant improvement in communication when pairing Spanish-speaking practitioners with Spanish-speaking patients. In a recent study, Guerrero and his colleagues examined the effects of cultural and linguistic competence in Latinos’ mandated substance abuse treatment (published in the August 2012 edition of Substance Abuse Treatment, Prevention, and Policy). Their study of 5,150 first-time Latino participants in court-mandated treatment programs revealed that the culturally congruent practice of providing Spanish language translation services increased participants’ odds of completing the treatment, notably amongst a population with a high risk of abandoning the treatment.
And, as cultural competence often results in more efficient, effective patient care, it not only benefits patients but potentially administrative bottom lines. So what are some of the other benefits of implementing culturally competent care, and how can nursing teams treating those struggling with substance abuse provide it? Guerrero and several experts in substance abuse treatment share their insights regarding culturally competent care below.
How does cultural competence improve the delivery of substance abuse care?
Roland: “In my experience over the last 40 years in nursing—and in particular over the last 20 years working in the field of addictions—patients who feel accepted, heard, understood, and validated for their strengths tend to do better in treatment. Clinicians who are aware of and knowledgeable about the diversity of cultures and subcultures that exist in the U.S. are in a better position to accurately assess, communicate, and individualize treatment. I believe that when people feel understood and supported within the context of their values and beliefs, treatment outcomes are better. Culturally sensitive clinicians aid the psychological and emotional well-being of their patients and, in so doing, will help foster and nourish a healthier self esteem, especially in substance abusers, who are generally filled with a lot of guilt and shame. Cultural competence should be incorporated into health care training and practice in order to maximize the opportunity for constructive change and recovery.”
Chandler & Degner: “Nurses need to have the ability to understand the cultural differences each substance abuse/ dependent person presents and must hone skills to correctly interpret non-verbal, verbal, and physical cues appropriately. Therefore, cultural competence training in serving substance abuse/dependent consumers is imperative to improve treatment delivery.”
How might nurses improve the cultural competence of their substance abuse care?
Chandler & Degner: “Nurses can improve their cultural competence and understand the culture in which substance abuse/ dependent populations exist daily. The substance abuser/dependent person will not focus on their substance(s) of choice but rather focus on the accompanying affective symptoms (depression, mood swings, anxiety, etc.). Hence, the outcome of working with this client may actually be perpetuating their addictive process.
There are specific cultural aspects of substance abuse/dependence in different populations as well. An example would be a Caucasian substance-abusing male as opposed to a Hispanic male. The very aspect of entering a treatment episode has different cultural barriers for each of these clients. Understanding these cultural differences will enhance motivational interviewing and will place the client at ease. What we view sometimes as resistance is attributable many times to cultural norms of the individual we are serving. Other cultural factors including religion, folk ways, family life, values, and so forth need to be considered when working with and providing medication to the client.”
Guerrero: “Continuing education in areas of cultural and linguistic diversity, as well as in the complexity of substance use and other co-occurring disorders. Informally, service providers benefit from personal and professional interactions with people and contexts that are from other cultural and linguistic backgrounds. These interactions, coupled with a nuanced understanding of the complexity of culture and language in mental health and provider client interaction, may provide nurses with the necessary ‘cultural intelligence’ to effectively engage minority clients. It is through the therapeutic alliance that we service providers have the greatest impact on clients’ attitudes about change.”
Roland: “Nurses can improve the cultural competence of their substance abuse care by ongoing education both academically and experientially. For example, nurses can advocate for regular in-service trainings about this subject on their jobs. Also, state and national organizations can offer conferences and panel discussions that could include minorities in order to get feedback on how we can improve in this area. Nurses working in addictions with minority patients have the opportunity to ask them directly for suggestions on how to improve our treatment specifically for them.”
Spanswick: “Each program tends to treat different problems but all professionals should try to take advantage of cultural competency classes offered by qualified professionals. Areas of cultural sensitivity include understanding different ethic backgrounds, the GLBTQ (Gay, Lesbian, Bisexual, Transsexual, and Questioning) community, and sensitivity surrounding economic status and class. Especially important is for practitioners to understand transference and countertransference issues so that they can try to be consciously aware of their relationship with the client and use tools to create a positive therapeutic join with the client and minimize the risk of clients leaving treatment. It is also extremely important to understand the current drug culture and trends. The most common issues regarding transference are anger and resentment towards the entitlement and denial of early stage addicts in recovery.”
What administrative steps can outpatient clinics adopt to deliver more culturally competent care?
Guerrero: “Quality assurance protocols need to go beyond checklists and rely on existing program evaluation tools to assess the level of cultural competence of their program. That information can inform a strategic plan to invest in areas of need (training, diversity, etc.)”
Chandler & Degner: “Administration is challenged with the opportunity to provide cultural diversity trainings for staff as well as education on alternate delivery methods. In-services training needs to be continual and learning needs to be focused on the various cultural aspects of all encountered aspects of client culture, including races, religion, sexual orientation, age group, etc. While we all cannot be experts, exposure to education over time can provide a broader base of overall cultural diversity within an agency.”
Roland: “Actively recruiting more diversity within the staff and administration is one way to help bridge the gap. Another suggestion is administrations could fund programs about substance abuse that will help educate as well as interest students in urban communities in this particular field of health care.”
Spanswick: “The best administrative step is using the skill of leading by example—administrators should be involved in training just as much as the treatment staff.”
What are some of the barriers to providing culturally competent substance abuse care?
Guerrero: “Individual providers face significant challenges to improve their cultural intelligence and culturally competent care, if they are limited to a monocultural life and professional environment. But the responsibility to develop a culturally competent health care extends beyond individual providers; managers and policy makers are responsible for developing adequate policy and organizational incentives for providers to engage in cross cultural training, implement evidence-based culturally responsive practices, and to track client outcomes. Substance abuse treatment providers are generally ill-prepared to implement new practices, including translation services, family based protocols, recruitment of diverse staff, cross-cultural training, etc.
In my research, I found that the major barriers to implement culturally responsive care are leaders and staff attitudes about the effectiveness of culturally competent practices and resources necessary to implement such practices. Interestingly, implementing such practices is not cost-prohibited; most programs have resources to translate material, prioritize hiring of diversity, or modify treatment protocols to include families in the treatment process. It is just not a priority until leaders support it or funding entities require it.”
Chandler & Degner: “The greatest barrier that exists in providing culturally competent health care is to be able to respond in an empathetic and supportive way to the client who presents for treatment. Many times it is our own fear of our knowledge base as it pertains to cultural differences. Training and education are key in meeting the demands and serving a more diverse population.”
“Another barrier, particularly in rural settings, is the lack of exposure to a more diverse consumer population. This, however, does not preclude those within the helping profession in these areas from exposure to a culturally diverse client base. . . . [We] need to educate ourselves and do what we can to understand emerging populations.
Additionally, the substance abuse/dependent population is ever changing, including the substances abused, the manner in which substances are abused, the background of users, etc. Referrals from businesses in the city as well as rural areas provide challenges for us to become better equipped and knowledgeable in understanding how to serve these many diverse populations and their very specific needs.”
Roland: “As an African American I can speak directly to some of the barriers that I know exist. There is a double stigma of being an addict and also being black in a predominately white culture where racism still persists. There is also—although I think this is changing somewhat—a stigma within the black community itself against getting psychiatric and addiction care. Many believe that giving one’s life to the Lord and going to church is all one needs for healing. . . . Other barriers are economic, as some people can’t take the time off from their jobs for treatment. Others, particularly women, may be hindered because of childcare issues. Homelessness and lack of adequate transportation or the money to travel to treatment facilities is also a problem. While some of these are barriers to health care in general, treatment programs may need more funding to hire clinicians willing to work evenings to facilitate groups and family meetings.”
Spanswick: The lack of diversity in hiring and organizational ‘group think’ and culture, which tend to be self-reinforcing of a singular cultural sensitivity—it’s important to try and join with clients from where they are at the point of admission.”
What resources or readings can you recommend to nurses wishing to improve the substance abuse care they provide their patients?
Guerrero: “For practice-oriented material, check with National Center for Cultural Competence website.”
Chandler & Degner: “The American Society of Addiction Medicine (ASAM) Patient Placement Criteria is a great resource. ASAM has provided substance abuse professionals with criteria that assist nurses in discerning the correct level of intervention needed for their patients.”
Roland: “A good article that I would recommend is ‘Cultural Competency: Its Impact on Addiction Treatment and Recovery’ from Resource Links, Volume 7 Issue 2.”
How has the delivery of care changed over the past 10 years and what work remains to be done?
Chandler & Degner: “The cultural diversity training presented 10 years ago was more cursory compared to today. Changes in population(s) served has driven a need for a more culturally aware and culturally competent staff. Population(s) across the U.S., both in the heartland and on our coasts, have changed drastically during the past 10 years.
Just the Stats The federal Substance Abuse and Mental Health Services Administration (SAMHSA), it its 2010 National Survey on Drug Use and Health (NSDUH), reports that approximately 22.6 million Americans over the age of 12, or 8.9%, are illicit drug users. Just over 22 million, or 8.7%, could be classifi ed as substance dependents or abusers. Of those considered dependent, 15 million abused alcohol but not drugs, 4.2 million abused drugs but not alcohol, and 2.9 million abused both. The NSDUH study also found rates of substance dependence or abuse according to race/ethnicity as follows (for 2010 amongst those aged 12 and older):
American Indians/Alaska Natives: 16%
Hispanics: 9.7%
Persons Reporting Two or More Races: 9.7%
Caucasians: 8.9% – African Americans: 8.2%
Native Hawaiians/Pacifi c Islanders: 5.6%
Asians: 4.1%
Even though every year we go through training on the topic of understanding cultural diversity, it does not meet the needs of the ever-changing consumer populations. We are more challenged to be knowledgeable about the cultural heritage of patients and how it impacts their care, now more than ever before. Because of the culturally diverse populations in rural communities and larger cities especially, we must improve our understanding of what the specific populations’ needs are and also change the way we provide treatment to ensure that we are responding to these more culturally diverse populations in the most effective way.”
Roland: “I think that awareness has definitely increased. There are more books, articles, and trainings on the subject. Years ago, this wasn’t even talked about. Mandatory trainings on the subject of cultural competence need to be implemented in health care institutions. Patients who are not part of the mainstream culture need to be asked how we can help improve in this area. Then these suggestions need to be implemented.”
Spanswick: “The field is constantly evolving and the types of drugs and the culture changes. I would say that the biggest change in the last 10 years is the use of prescription opiates and crystal meth, which has required clinicians to use more family-based education as to what is and what is not a drug that is likely to become one that carries more danger. It is appalling how many ‘drug addicts’ become accidental abusers of prescribed medication—this is something we see too often at KLEAN Treatment Center.
As a field we are just beginning to understand addiction and how the brain works. As science progresses, I believe the medical models will become much more sophisticated and will dominate the field. Culturally we have made huge strides in the past 50 years but there is always room for more understanding, especially as cultures are constantly evolving. Most importantly we need to constantly remind ourselves that every client is different, all have unique issues, and it is the primary relationship between clinician and client that can produce the greatest outcomes in the long term.”
“Kuleana means having a sense of place in society such that each person has a right to basic necessities needed to sustain oneself—security of housing, food, health care, transportation, safety, and justice—and in turn has a responsibility to contribute to the sustenance of society,” Boyd says. She likens this sentiment to “client rights and health care ethics” in the Pathway program.
A contrast to the vacation resort paradise with which the continental 48 are so familiar, Hawaii actually experiences a great deal of socioeconomic instability. Pathway out of Poverty helps the impoverished, particularly native Hawaiians, build self-reliance and guides them toward a career in nursing.
Teaching since 1998, Boyd is currently an assistant professor at University of Hawaii, Windward Community College in Kaneohe, in addition to serving as Director of the Pathway out of Poverty program. In her own words, the program is “a curriculum based in Hawaiian values and traditions of healthy living that leads underserved community college students through a nursing pathway from Nurse Aide (NA) to Licensed Practical Nurse (LPN) to Registered Nurse (RN), with inherent increases in wageearning potential.”
Boyd won the Robert Wood Johnson Foundation Community Health Leaders award in 2011 for her commitment to improving health care in her community while overcoming immense personal obstacles. She received $20,000 for personal growth and a $105,000 grant for the Pathway program. The grant’s mission? “To support and sustain the capacity of individuals who demonstrate creativity, innovation, and commitment to improving health outcomes at the community level.” This mission was well served in honoring Boyd’s life and work.
From the ground up
When her guardian grandmother died, Boyd found herself in a much darker world. “My grandmother instilled in me that I was a precious blessing on earth. After she died and I went to foster care I was told that I was fortunate to have food on a plate or a roof over my head,” she says. “I was given old tattered clothes while foster parents bought new clothes for their own daughters. I was made to scrub toilets while other kids played outside. It sounds Cinderella-ish, but it’s true.
Boyd accepting the Robert Wood Johnson Foundation Community Health Leaders award in 2011
“I was warned that if I didn’t surrender I would be put on the street,” Boyd says. “I found myself 13 and pregnant. After my early childhood with my grandmother I was never again told in my youth that I was a blessing. I knew inside that my blessing was to help others.” Through this experience, Boyd says she learned “society treats the havenots as want-nots,” casting them aside. But she convinced her social worker she could live as an independent, and went on to complete nurse training and education up to her Ph.D.
“I was fortunate to have come across folks in my own path out of poverty that held knowledge about supports for have-nots: orphaned, teen mother, impoverished, minority,” Boys says. One of the folks was Kathryn L. Braun, Dr.P.H., Boyd’s Ph.D. mentor and a professor of public health at the University of Hawaii. They met through Braun’s work with `Imi Hale, The Native Hawaiian Cancer Research Training Network, and Braun also served on the University of Hawaii’s dissertation committee throughout Boyd’s doctoral studies.
“I have always been inspired by Jamie, who overcame many obstacles to get where she is today,” Braun says. “The road was difficult, but it has motivated her to help others ascend the path out of poverty through education and service.”
From the early days, when Braun was helping her mentee obtain research funding from the National Cancer Institute, to now, where they support each other’s professional pursuits and even room together at public health conferences, the two women forged a close, supportive relationship. “As a Native Hawaiian I could not have completed my Ph.D. training without her dedication to mentoring NH [native Hawaiians] and other Pacific Islanders,” Boyd says of her mentor. Braun also notes that Boyd is one of the state’s first Ph.D. nurses to come from an indigenous background.
“She declined a [University of Hawaii] research position in favor of [Windward Community College], so she could reach Hawaiian and other disadvantaged students,” Braun says. Originally charged with developing a health curricula that would help get students “done and out,” Boyd recognized the deficiencies and disparities plaguing her vocational students. “They are not eligible for federal financial aid or student health insurance, WCC provided no graduation ceremony for NA graduates, and there were no supports to transition graduates to living-wage jobs,” Braun says. “She worked to convince WCC to approve a ‘pathway’ approach, helping transition NAs to the Associate Degree in Nursing. She worked nights and weekends to secure financial and in-kind resources to reduce barriers facing students, which won WCC and community support.” Boyd also steered the WCC’s administration toward indigenous teaching models.
“I always had the capacity to give and would have to work very hard to earn resources to experience the privilege of helping others,” Boyd says. “I learned that every individual who presents as a ‘have-not’ may hold within the potential to make lasting positive change.”
On the Pathway out of Poverty
Native Hawaiians seem to have the deck stacked against them: they are more likely to hold low-paying jobs, lack health insurance, suffer from chronic disease, and drop out of school. According to Boyd’s 2007 article “Supports for and Barriers to Healthy Living for Native Hawaiian Young Adults Enrolled in Community Colleges,” “in 2000, 72.5% of Native Hawaiians were overweight, 54.4% met national recommendations for physical activity, and about 10% enrolled in college.” They are underrepresented in areas that count, like amongst college students and health care practitioners. Because of these disparities and others, Boyd is taking action.
At the crux of Boyd’s efforts to improve the health and socioeconomic livelihood of indigenous Hawaiians is the Pathway out of Poverty program: “A Values-Based College- Community Partnership to Improve Long-Term Outcomes of Underrepresented Students.”
Boyd points to a snowball effect in native Hawaiians’ achievement levels: students do poorly in the K–12 levels and cannot gain entrance to public universities. After years of insufficient grade school support, and consequently poor achievement, they’re also unprepared to enter fields like nursing. “But we naturally give so much to community and have a natural aloha to care for the sick,” she says. “We need for Hawaii universities to stop social exclusion behaviors of our early colonizers and allow Native Hawaiians to selfdetermine entrance criteria to nurse training in Hawaii.” The alternative? “Allow me to create the first Indigenous School of Nursing that is inclusive of Native Hawaiian values and cultural practices.”
Boyd reports 135 students, or 90%, of those who have participated in the first three and a half years of the program graduated and became certified nurses assistants; 77 of those individuals went on to higher education, including 33 entering nursing programs.
“Her vision is to reduce poverty and increase representation of Hawaiians in nursing,” says Braun. “Toward that end, she secured critical partners and more than $1 million to build . . . Pathway out of Poverty.”
What nurses can do
“There are big gaps between resources that slow people’s potential to heal themselves,” Boyd says from experience. “My motivation is to eliminate gaps and create a steady, continual path out of poverty.”
It’s not about handouts, Boyd says. It’s about education. “Don’t give childcare; provide centers for child care co-ops,” she says. “Don’t give food; protect land to grow food or designate certified kitchens where [the] disadvantaged can feed each other.”
To that end, Boyd recently secured funds and began developing a “Seed to Plate” curriculum, says Braun. “Pathway students use the garden as a healthy foods ‘lab.’ Recognizing Jamie’s success in nursing and Hawaiian educational approaches, she was asked to join with faculty in botany and nutrition to build cross-disciplinary learning communities that aim to impart Western knowledge while honoring Hawaiian traditions for healthy living.”
Boyd’s Ph.D. dissertation defense. Committee members (left to right): John Casken, R.N., M.P.H., Ph.D.; Kathryn Braun, Dr.P.H.; Boyd; (chair) Chen Yen Wang, A.P.R.N., Ph.D., Lois Magnussen, A.P.R.N., Ed.D.; Bee Kooker, A.P.R.N., Dr.P.H.
Boyd says those who are working diligently should be awarded with “change credits,” like those given to her by the Robert Wood Johnson Foundation. Boyd’s life’s work, her ultimate goal, is to reduce poverty and health disparities amongst indigenous and minority populations. She intends to do so through education, advocacy, and tapping into native teachings. Her solutions draw upon economic and cultural research. In the end, these people will have brought themselves out of poverty. “Through my volunteerism, peer mentorship, publication, and dissemination I help other underserved, and together we pull ourselves up and in turn again pull up even more.”
Lisa Zick-Mariteragi, A.P.R.N.-R.X., M.S.N., M.P.H., an advanced practice nurse practitioner in internal medicine, worked with Boyd at Waianae Coast Comprehensive Health Center in 1998– 1999. “Jamie was a NP student at the time and knew that I took students who had a vested interest in improving health outcomes for indigenous populations,” Zick- Mariteragi says, who agreed to mentor the eager student. “She had a very clear picture in her mind of where she wanted to go professionally and what she needed to do to get there.” Zick-Mariteragi says Boyd, even then, was focused on the bigger things beyond the horizon of her graduate studies.
“Based on, among other things, the Native Hawaiian principles of ‘Ohana, Aloha (appreciation), Laulima (work), Lokahi (unity), and Malama (service), Jamie has been able to create a venue and provide access for disadvantaged individuals to improve their own lives by addressing their social, cultural, educational, familial, and fiscal needs through her programs,” Zick-Mariteragi says. “She demands commitment from them to pay back— not to forget where they came from—and forward-extend a hand to those in greater need than themselves.”
Sharmayne Kamaka, C.N.A., experienced that demand firsthand. She was one of the first Native Hawaiians to join Boyd’s Pathway program. The two met at Windward Community College, where Boyd served as Kamaka’s CNA instructor. “My first impression was that I thought I couldn’t meet her expectations. She was very strict, yet loving at the same time,” Kamaka says of Boyd. “I felt a magnetic pull toward her ‘mana.'” But over the four years they have known each other, that intimidation gave way to deep admiration and a strong mentoring relationship.
“Without Jamie, I wouldn’t be where I am today,” Kamaka says. A divorced mother of five when she met Boyd, Kamaka couldn’t afford to begin her CNA training, but Boyd helped her do the legwork needed to secure funding. “Four years later, I am on the dean’s list, a Phi Theta Kappa member, and a KCC Practical Nursing Student [graduate],” Kamaka says. “Without all the countless selfless hours of Jamie writing grants and securing contracts and community partnerships, I would have given up. It was always a dream of mine to become a nurse. Jamie is making it possible for my dream to come true.” But Boyd says Kamaka is “fulfilling her own dream….She hasn’t gotten anything she didn’t work very hard for.”
Visions of the future
Zick-Mariteragi says she imagines Boyd will continue to grow the Pathway program; to surprise her colleagues with her unstoppable energy; and to make her kupuna (ancestors), her keiki (children), and her mo’opuna (grandchildren) proud. “All that she is, all that she’s done, she’s truly fought hard for. Determined, focused, passionate, humorous, pressed to improve the outcomes for native peoples by creating models of personal and community development—quite literally from the ground up,” Zick-Mariteragi says. “Though I was her mentor before, she could be mine now.”
Braun says she also imagines Boyd simply continuing her current trajectory: reaching out to the community to engage students and administrators, health care providers and funders alike.
Kamaka imagines Boyd establishing Hawaii’s first indigenous nursing school, with buildings named after her. “She is definitely a community leader and should be recognized as such,” Kamaka says.
And what does Jamie Boyd imagine for herself? Her ultimate goal is, indeed, to create a school of nursing for indigenous peoples, she says, combining traditional healing with cutting-edge medical technology—and social justice training to boot. She hopes the disparities affecting native Hawaiians and other underserved populations become a non-issue.
Yet, as long as they persist, and perhaps simply because they persist, disparities and deficiencies make so many people feel helpless—particularly the people living them. Then, someone fights back. Though disparities often prove stubborn, when confronted with individuals determined to eradicate them, they can topple. Jamie Boyd is one such fighter, armed with her cultural roots, her resolve, and her Pathway out of Poverty program.
“For every gain I experienced, I promised to turn back and pull up 10 just like me,” Boyd says. “I’ve already pulled up 10, and I’m still going strong.”
