Jacqueline Daughtry grew up in Montego Bay, Jamaica, but she moved to the United States to pursue a career as a cosmetologist. After 17 years in cosmetology, however, Daughtry decided to pursue a second career. Considering her family commitments and her interest in medicine, she chose to complete a university degree in dietetics. After graduating, Daughtry was readily accepted into an accredited dietetic internship program. Now, as a clinical dietitian, she allowed me to spend the day with her at the Regional Medical Center in Memphis, Tenn., in order to present to the readers of Diversity: Allied Health Careers just what it takes to be a clinical dietitian.
Daughtry is one of six clinical dietitians in food and nutrition services at the Regional Medical Center. Located in downtown Memphis, adjacent to The University of Tennessee Medical School, the 350-bed, state-funded hospital is home to multiple Centers of Excellence including the Burn Center, High-Risk Obstetrics, Newborn Center, Elvis Presley Memorial Trauma Center and Wound Care Center.
According to Daughtry, her favorite aspect of her job is working with a diverse patient population that has a high acuity level. She also likes being part of a medical care team but appreciates the autonomy she has in managing her patients’ nutritional needs. Daughtry enjoys working in a teaching hospital and interacting with allied health and medical students.
Characteristics that help Daughtry excel as a dietitian include her organizational skills, ability to multitask, positive attitude, flexibility and interpersonal skills. She’ll quickly tell you that the rewards of her job outweigh any negative aspects. Daughtry loves teaching patients why it is important to make specific dietary choices. She promotes the teaching philosophy of “meeting the patient where they are.”
Many opportunities are possible for Daughtry as a registered dietitian. In the future, she foresees completing a master’s degree to become a clinical nutrition manager or education coordinator.
8:00 a.m. In any given workday, Daughtry is responsible for the nutritional care of patients in the medical-surgical, rehabilitation, obstetric-antepartum, postpartum and progressive care units. Each morning, in her office, she plans and organizes her day by first reviewing her computer printouts. She checks the printouts to screen for albumin levels, MID ordered consults, surgery patients, modified diet orders and nutrient/drug interactions.
At her desk with printouts in hand, Daughtry eats a bowl of instant oatmeal and makes notes about three patients with albumin levels suggestive of moderate to high nutritional risk, a new admit over 65 years of age who is scheduled for surgery, an anteparturn patient under 17 years of age, a postpartum patient with a two gram sodium diet order and three medical dietician consults. Over the course of the day, Daughtry will interact with patients from 13 to 92 years of age.
9:00 a.m. Daughtry’s first stop is at the newly redone 20-bed Rehabilitation Hospital of Memphis that is located within the Regional Medical Center. She is involved in the discharge planning of rehab residents each week. She evaluates tube feedings and monitors weight, nutritional lab data and dietary intake of the residents. Daughtry has MD approval to write nutrition orders as needed. Today, she reviews lab data on the unit computer and checks the medical charts of three residents. She visits a 92-year-old new admit with cardiovascular disease who also has aphasia. Daughtry notes her breakfast tray, asks about her food preferences and checks her weight. After visiting a patient who has been in the hospital nine days and a 17year-old patient, Daughtry enters nutritional progress notes in their charts. Daughtry also interacts with the nursing staff and the nurse manager.
10:30 a.m.
At the Obstetrics-Postpartum, Unit, a consultation has been ordered for a postpartum mom who is considering breastfeeding. Daughtry reviews her chart and checks her current lab data. She was admiitted with preeclampsia and has high blood pressure and,an elevated albumin. A review of her medications, unfortunately, indicates that she should not breastfeed. Daughtry discusses infant feeding options with the mother. The new mom seems relieved, confident and appreciative of having the facts to guide her in feeding her new baby.
11:05 a.m.
Daughtry’s pager rings. She wears a pager at all times while at work. An RN is requesting diabetic nutrition education materials for her nursing students. Daughtry encourages her to send the students to the patient diabetic education classes offered today to learn about the diabetic diet. They agree this will be more effective than just providing the diabetic nutrition handouts.
11:15 a.m.
At the general ICU, the dietician is on vacation; so Daughtry checks on a consult to evaluate a tube-feeding regimen. She is pleased that another registered dietician has already: responded to the consult. Having the ability to multitask is an important part of the job. On the
unit, Daughtry takes the opportunity to interact with the speech therapist about a mutual patient. Daughtry is a member of the hospital dysphagia team and works closely with the speech therapist.
11:45 p.m.
Back in the nutrition office, Daughtry checks to see if any other consults have been ordered. She typically eats lunch at her desk while completing paperwork. Tomorrow afternoon she is invited to present a nutrition education program for a third grade class of about 80 children. Community outreach is valued by the hospital
administration, so Daughtry, spends some time preparing for this presentation during her lunchtime. Daughtry also volunteered and was selected to serve as a professional mentor for minority students majoring in dietetics at The University of Memphis.
1:00 p.m.
The Progressive Care Unit is a 16 bed step-down unit from ICU. Daughtry is responsible for eight of the beds there. She checks the recent labs on her patients and the Admission Health Assessment Form for a new patient. Although the new admit is at low nutritional risk, he is on a two gram sodium diet. He is coherent and complaining that he did not get any meat for breakfast. Daughtry talks with him about his dietary restrictions. They determine that he wants more food. Daughtry decides it would not be appropriate to send him low sodium bacon since it would not be available at the residential facility where he resides. Instead she decided to provide larger servings of his favorite breakfast cereals and will monitor whether or not these larger servings satisfy him in the future. Daughtry uses the hospital meals as educational tools whenever possible. She fills out the appropriate charts on this patient.
2:30 p.m.
Back at the Medical-Surgical Unit, the nurse manager talks with Daughtry about dietary problems she is having following removal of her gallbladder. After a few questions Daughrty provides her with several suggestions that are well received and appreciated. Unit tabs are checked. A patient’s low albumin is determined not
to be nutrition-related. A follow-up visit with a diabetic patient allows Daughtry to clarify some information and respond to dietary questions. She completes charts on several patients.
3:45 p.m.
Daughtry provides dietary instruction for a patient with cirrhosis who is being discharged. She also visits a patient scheduled for testing who has to restrict red food coloring.
4:15 p.m.
In Daughtry’s office, she interacts with other registered dieticians about the Performance Improvement Project for Clinical Nutrition that is ongoing. She completes her log of activities for the day and will be able to leave work by 4:30 p.m. today. She works Monday through Friday and every sixth weekend. A perk of her job is that she has “flex time.” She may need to come in early or leave early one day, This enables her to balance personal and professional commitments. She is usually able to arrange her schedule so she can attend her children’s school programs, make dentist appointments, teach an aerobics class for employees and more.
Poor eating habits and lack of exercise among African Americans increases their risk of developing cancer, obesity, hypertension, diabetes and heart disease, according to recent studies by the Public Health Institute (PHI) and the California Department of Health Services (CDHS).
Health care professionals at the Charles R. Drew University of Medicine Sciences (CDU), a medical school and college in Los Angeles that provides health care to underserved populations, believes this trend of poor nutrition in African Americans is a cause for concern.
CDU President Charles Francis, PhD, says, “We see evidence of this every day in our [African American] patients who have a higher incidence of obesity-related diseases, such as diabetes and hypertension, than the rest of the population.”
CDU is especially concerned with the poor eating habits and sedentary lifestyle of many black youths. PHI studies have found that black teens are spending less time participating in physical activity and more time watching TV, playing video games and using the computer. In fact, African-American teens spend an average of 188 minutes a day watching television, compared to other young adults who average 130 minutes a day. Black teens also have poorer nutrition, according to studies by the CDHS that found that this group eats too few fruits and vegetables, too many high-fat foods and is increasingly overweight.
But African-American teens are not the only ones participating in these unhealthy behaviors, the study concludes black adults’ increased risk of many types of disease is, in part, a result of their own poor nutrition and lack of exercise.
“Our people are dying,” says Elaine Williams, PhD, a doctor at CDU. “This is real for us. Health disparities in this country widen every year, and this chronic condition is threatening our lives.”
To combat this trend of poor nutrition and lack of physical activity, the CDU challenges African Americans to take it upon themselves to follow healthy dietary guidelines, such as eating at least five servings of fruits and vegetables every day. The university’s Task Force for Nutrition advises black teens and children to increase their physical activity to 60 minutes a day and encourages black adults to exercise for at least 30 minutes a day.
The National Institute of Nursing Research has given the University of Alabama at Birmingham (UAB) a four-year, $1.3 million grant to study how parents should encourage responsible self-care in adolescents with chronic illnesses such as diabetes.
“This is the first study of its kind to look at the development and self-care of adolescents with insulin-dependant diabetes in relation to family interactions and to follow these families for an extended period of time,” says Carol Dashiff, PhD, professor and chair of nursing graduate studies at UAB.
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The study will include 274 adolescents, ages 11 to 15, with Type 1 insulin-dependent diabetes. The disease, which affects approximately 1.2 million children in the U.S., requires daily injections of insulin. “If not properly managed, it can lead to serious health problems and can be life threatening,” Dashiff says. “The demands of daily monitoring are stressful for adolescents and parents.”
The study will include a group of African-American teens with Type 1 diabetes. “This is significant because African Americans are often not well represented in studies done in this area,” Dashiff states. “It’s important because what fosters responsible independence and self-care among black teens may be different than among white adolescents, so we will be looking at cultural differences and what impact they have on adolescents’ development.”
During home visits researchers will evaluate how teens and their parents discuss and resolve typical adolescent-related issues and diabetes management issues. “This will help us identify some characteristics of families that help facilitate responsible independence and self-care,” Dashiff says. “It will provide us with insight into parents’ and adolescents’ perspectives, how they differ and how these differences may affect development of independence and self-care.”
As a result of the study, researchers hope to develop programs and material to help parents foster their children’s independence in diabetes control. “Parents of chronically ill children often ask for guidance in making decisions about how much independence to give their adolescents and in what areas,” Dashiff says. “This study will help us develop those guidelines.”
A new study released by the University of Chicago Children’s Hospital finds TV shows geared toward African-American audiences have more overweight characters and 60% more food commercials than shows that attract a general audience.
In addition, 31% of the food commercials on popular black shows are for sweets and 13% are for soda. On shows for general audiences, only 11% of the ads are for sweets and only 2% are for soda.
African-American shows also have a higher number of obese characters than shows aimed at general audiences –27% of actors on black shows are overweight, but only 2% are overweight on general audience shows.
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According to Manasi Tirodkar, an author of the study and research assistant at the University of Chicago’s Children’s Hospital, the programs could be a reflection of weight status in the African-American population, which may help to lessen the stigma associated with being overweight.
While overweight characters portraying self-confidence is a good thing, if those characters are shown eating junk food and participating in other unhealthy actions, they may be viewed as endorsing behaviors associated with obesity, Tirodkar believes.
“The ads and programming content [on black TV shows] may influence the eating behaviors of African Americans,” says Anjali Jain, PhD, senior author of the study and an instructor of pediatrics at the hospital. “More than 60% of African Americans are overweight, compared to 54% of the general U.S. population.”
Obesity increases the risk of many life-threatening diseases like diabetes, hypertension, cancer and heart diseases, all of which are more prevalent in members of racial and ethnic minorities than in whites.
“We know from previous studies that television influences health behaviors, for instance those related to alcohol and tobacco,” Tirodkar states. “In the long run, this may prove to influence obesity, the way alcohol and tobacco advertising have influenced other heath behaviors.”
Shiriki Kumanyika, a professor of epidemiology at the University of Pennsylvania, says the prevalence of overweight black characters in these shows is a mixed blessing. “It’s nice to have a diverse group of African Americans portrayed on TV–the overall acceptance of different weights has to be addressed. I certainly don’t think we should get into portraying unattainable images,” she says. However, Kumanyika points out, the underlying health issues of overweight characters must also be addressed.
Imagine for a moment that you are a patient in a hospital that is unable to meet your special dietary needs. What are you going to do? Would you sign out against medical advice and go to another health care facility that can accommodate your requirements, even if its medical care is not known as the best?
The health care profession, like any other profession, has been forced to adopt customer-oriented service models. Logically, the best customer service model is to provide whatever is necessary to please every customer. In reality, of course, this model presents many challenges within the health care environment because of the many restrictions and contingencies, such as time, hospital policies, patient privacy and legal factors.
One of the biggest “customer service” challenges for nurses and other care providers is being able to meet the unique needs of patients from a wide variety of cultural, ethnic and religious backgrounds. Applying the adopted customer-oriented model within the context of nursing requires advanced assessment and validation skills whenever caring for our “customers” (patients). With this notion in mind, care providers are expected to be sensitive, open, flexible and able to meet these unique “customer” needs as appropriately as possible and at all times. Remember, cultural needs are not a luxury; they are a necessity and a part of the basic patient’s bill of rights.
Performing dietary assessments is one key area where nurses must develop cultural competency skills. Being knowledgeable about the dietary needs of different cultures and religions—including preferences, customs and restrictions—and how they may impact a patient’s care plan is essential to providing customer-oriented patient care. The following recommendations for conducting a dietary culturalassessment can guide nurses in reaching the desirable level of cultural sensitivity.
The art of asking the right questions—rather than making assumptions based on preconceived notions or stereotypes about various cultural, ethnic or religious groups—is the key to conducting a culturally competent dietary assessment. Here are some considerations to keep in mind.
Remember that each patient is a unique individual. Just because a certain culture, ethnicity or religion has dietary traditions or guidelines, that doesn’t necessarily mean that every person who is a member of that group adheres to them. Nurses must determine whether the patient follows his/her cultural guidelines, and if so, to what extent. E.g., does he/she follow the guidelines strictly or liberally? When dealing with immigrant populations, special attention must be paid to issues such as length of time the person has been living in the United States, whether the person is first or second generation, and degree of assimilation into the American and/or other cultures.
Understand the significance of patients’ personal food habits and preferences in relation to cultural norms. For example, just as buttering the bread is an essential habit for Americans, so is cooking with soy sauce—which is high in sodium—in many Asian cultures. Asking Asian renal or heart patients not to use soy sauce in cooking is like asking Americans not to butter their bread. However, asking them to switch from regular soy sauce to a low-sodium brand of soy sauce can decrease their total salt intake by half.
When asking about foods the patient eats, keep in mind that patients who are recent immigrants to the U.S. may not be familiar with American food names or dishes. This problem can be solved by using pictures of foods. I cite this example based on my own personal experience: When I first emigrated to the America from Egypt, I felt no need to learn the American names of food until I had to study them in order to pass my NCLEX-RN® examination!
Investigate whether the patient’s dietary restriction is a cultural norm, a personal preference or a religious mandate. This is a vital element when serving meals and different food items. For example: for Muslims, who religiously are not allowed to eat pork or any part of the pig cannot eat from any dish or food utensils used or touched pork and pork products. It is considered a contaminated item and they expect to eat from a new clean dish and utensils that are completely free from any pork or pig traces. This restriction is true for Muslims as well as other faiths such as Judaism, Hinduism, and vegetarians.
Being very specific when asking about a main belief system such as Christianity. This is not enough; investigate more about the uniqueness within this belief system such as Seven Day Adventist, Mormon, Jehovah’s Witness, etc. For Example; an insulin diabetic patient needs few snacks per day, which is quiet normal to many Christians. For some Seven Day Adventist believers; they are dominantly pure vegetarians, it may be more appropriate for the care provider to suggest dividing the three main meals into five or six small ones rather than suggesting eating snacks between meals. Eating between meals is not a favorable habit for some Seven Day Adventist believers.
Inquiring about special habits or religious practices desired to be performed before/after a meal and/or any food item. Facilitating such desires or practices can positively impact on the level of the patient’s compliance with the prescribed plan of care including any dietary restrictions and enhance health recovery.
Folk Practitioners or Corandero Practices
Asking about the prescribed pharmacological/herbal treatments and visits to the folk practitioners need to be an essential part of our assessments. Being aware of the existing combination is a safety issue for both the patient and the care providers. In fact, we need to acknowledge the hidden competition of the Folk Practitioners existence in almost every culture, including the US. He/she is an experienced person in prescribing effective herbal treatments, home remedies, dietary management, etc. that are easy to follow and are quite inexpensive. The folk practitioner has almost a treatment for every illness, sickness, and/or all different kinds of health problems. Their repeated home visits for the sick are one of their key strategies for gaining great success among the poor, elderly, lonely, and the disabled population.
For example, physicians prescribe expensive nitroglycerin sublingual tablets for Anginal pain that usually expires within 6 month contrasting the Corandero/Folk Practitioners who prescribe peppermint oil that never expires and costs only a few dollars. Applying a few peppermint oil drops in the mouth has a very close vasodilatation effect on the body. Of course the elderly, no insurance, and limited income populations will select the peppermint regime especially if it can manage their condition effectively. Another factor for the folk practitioner’s success is teaching their patients effective complementary dietary practices such as drinking very light tea with plenty of natural mint leaves. The constant effect of the mint leaves on the blood vessels may easily keep some patient populations free from chest pain.
Whenever discovering the mix of the non-traditional and pharmacological medications, that are widely spread lately, it is very serious to ask the patients to continue or stop taking this combination. Especially if we do not know that much about these practices for the following reasons:
Keeping in mind that the patient has already made a conscious decision to take such therapy or combination of therapies.
What is being used may be a placebo to sooth the emotional status with no medical significant effect.
The patient may already stop taking the traditional pharmacological medications and is currently only using something that has a very similar effect to the prescribed pharmacological medication.
The patient is combining both therapies because one of them is not enough or not effective for the current health condition.
The patient is experiencing current side effect of one or both therapies without realizing the significance of them.
Conducting further physical and psychological assessment evaluating the effect of each therapy on the current health condition is a must before altering or stopping any of these therapies. Logically and scientifically, if assessment reveals a healthy condition, regardless of what is being used currently, it means that it must be working right for that patient or illness and why not keeping it and wisely ask for more frequent assessment visits as needed.
The best approach in similar cases is to continue dietary/herbal cultural assessment focusing on the following issues to reach a safe, sound, and legal decision:
the current use, action, side effects, and the length of use.
any possible addiction effect whether physical or emotional, and assess the current addiction signs and/or symptoms if they exist.
the current combining: prescribed pharmacological medication, herbal, and the folk treatment.
the current health condition while using or not using this combination.
Because there is no equivalent of FDA approval for most of these folk remedies, ask the patients for any documents or sources of information to gain in depth of information for any unfamiliar herbs, un-known therapies, and/or non-traditional ones. If nothing is available in English, there are many herbal and non-traditional books available in the public libraries, different bookstores, and university’s libraries that teach cross cultural programs. Internet searches may also be performed to reach countless English websites. Also, we need to accept that the patient is a source of such information whether documented or not. He/she is the one who knows most about these therapies and why he/she decided to try it/them.
Editor’s Note: Minority Nurse’s cultural competence expert, Gihan ElGindy, RN, MSN, is an internationally recognized authority on cross-cultural issues in nursing. Her advice column is designed to answer your questions about incorporating cultural competence into your nursing practice and resolving cultural conflicts in today’s diverse health care workplace.
