Using evidence-based practice (EBP) to give patients the best possible care is one of the hottest topics in nursing today. Yet evidence-based nursing is not a new model of care. In fact, says Linda Burnes Bolton, DrPH, RN, FAAN, vice president and chief nursing officer at Cedars-Sinai Medical Center in Los Angeles, it is simply another way of looking at the traditional theme of nurses living up to their sacred trust with society.
“The sacred trust is based on the belief that nursing professionals will always act in the best interest of the patient,” Burnes Bolton explains. “We cannot do that without knowing what would best benefit and assist the patient. Part of that trust and commitment to patients is to give the very best care for each individual. We cannot be lulled into a false sense [of security] that it is OK to do something just because ‘this is the way we have always done it.'”
These days, it’s hard to open up a nursing magazine and not see an article about evidence-based practice. But because it’s a complex concept, many nurses still don’t completely understand what EBP is all about.
One of the best explanations of what EBP is and is not comes from Bernadette Melnyk, PhD, RN, PNP/NPP, FAAN, FNAP, dean of Arizona State University (ASU) College of Nursing & Healthcare Innovation in Phoenix. Three years ago, Melnyk founded the nursing school’s Center for the Advancement of Evidence-Based Practice (CAEP), one of a handful of university-based centers across the country dedicated to this paradigm of care.
Speaking at the 2006 National Black Nurses Association annual conference, Melnyk noted that “improving health care through EBP is a problem-solving approach that integrates the best research data with the nurse’s clinical expertise and the patient’s individual needs and preferences. It is not just research utilization or translating research into practice. It’s the process of synthesizing the best evidence across multiple studies to come up with what’s best for [that particular patient in that particular situation].”
With its emphasis on developing interventions based on sound clinical evidence and proven best practices, evidence-based practice is an ideal tool for nurses to use in their efforts to eliminate racial and ethnic health disparities. Yet using EBP in the specific context of improving minority health outcomes poses unique challenges—from where to find research data that is inclusive of minority populations to understanding how culture and language may influence a patient’s preferences.
Defining EBP: A Closer Look
David Sackett, MD, a Canadian physician, is considered the father of evidence-based practice, according to Cheryl Fisher, MSN, RN, program manager for professional practice development of nursing and patient care services at the National Institutes of Health (NIH) Clinical Center. Located in Bethesda, Md., the center is the nation’s largest hospital devoted entirely to clinical research.
Fisher has adopted Sackett’s definition of EBP. “He states that evidence-based practice is ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. . .[by] integrating individual clinical expertise with the best available external clinical evidence from systematic research.’ In our hospital setting, we also take into consideration the patient’s preference since our care is patient-centered.”
Searching the literature to find the best evidence doesn’t have to be an overwhelming or time-consuming process. To target their search and quickly find the relevant research, says Melnyk, nurses should formulate a clinical question using the PICO framework:
P = Patient, Population, Problem
I = Intervention
C = Comparison
O = Outcome
“When you phrase questions in that way [with these criteria in mind], you will not spend days and days searching for the evidence to answer your question,” she says. “You will know how to put key words from PICO into a database search and rebuild your answer in a short period of time.”
Once you have come up with the key words to focus your inquiry, the next steps in the EBP process are to:
1. Search for the best research studies relating to your question;
2. Do a rapid critical appraisal of the research findings;
3. Integrate the evidence with your clinical expertise as well as the patient’s circumstances and preferences; and
4. Evaluate the outcome in the context of your own practice setting and, if necessary, make changes to current practices to give the patient better care.
A rapid critical appraisal helps clinicians establish the validity, reliability and patient applicability of a study or group of studies and find the most important nuggets of evidence to use in their practice. “And then you have to make the decision as to whether or not you are going make a practice change and integrate Step 4,” Melnyk says.
For Adelita G. Cantu, PhD, RN, a clinical instructor in the Department of Family Nursing Care at the University of Texas Health Science Center at San Antonio School of Nursing and a researcher who focuses on Hispanic health disparities, EBP means looking at what clinicians are doing on a daily basis, looking at patient care and knowing it is based on research. “You need to know there is some evidence that says this is the way you should do it and why you are doing it,” she emphasizes. “[As nurses], we need to explain to the patient why something is being done and that there is a reason it is being done a particular way. That should translate into better patient compliance.”
Sandra Millon Underwood, PhD, RN, FAAN, American Cancer Society Oncology Nursing Professor at the University of Wisconsin-Milwaukee College of Nursing, is a researcher who has devoted much of her work to cancer prevention and early detection among medically underserved minority populations. She cautions against taking too narrow a view of what EBP can accomplish. All too often, Underwood says, when clinicians think about evidence-based practice they focus solely on using the data from research to guide decisions.
“I think in many ways that is short-sighted, because most evidence-based practice models expand that vision,” she explains. “The evidence and research is critical but so are the other domains of EBP in making decisions for individuals, for communities and for population groups at risk.”
Underwood believes there are six domains that come into play when using EBP: scientific evidence, clinical experiences, the resources that are available within the academic arena or clinical environment, patient preferences, patient condition and patient characteristics.
The Importance of Inclusive Research
One of the biggest challenges nurses face in using evidence-based practice to address minority health disparities is finding enough evidence that is relevant to the needs of minority patients. There are many areas of medical research where people of color are underrepresented in clinical studies, or not included at all.
Burnes Bolton stresses the need to use research that is based on minorities to treat these populations. She points to skin cancer as an example. Skin assessments for people with dark skin will be vastly different than those done on Caucasians. “Generally, you look for changes in a [mole or spot on the body] where the skin is a different color,” Burnes Bolton explains. “With African Americans, they may not be able to see that.”
To share resources in support of evidence-based projects for reducing Native American health disparities, nursing leaders from the National Institutes of Health, the Indian Health Service and the National Alaska Native American Indian Nurses Association teamed up to create a collaborative online community
The end result can be deadly. According to the American Academy of Dermatology, failure to recognize skin cancer in people of color can lead to late diagnosis and lower long-term survival rates—only 58.8% compared to 84.8% for Caucasians. Furthermore, many people are under the misconception that melanoma is not a threat for individuals with darker skin. And studies of African Americans who are diagnosed with melanoma highlight another relatively unknown fact: In African Americans the condition most often develops on areas of the body that are not exposed to the sun.
“You can’t only use skin texture as a factor,” Burnes Bolton says. “You have to ask patients questions in a culturally appropriate manner.”
Another example, she continues, is the effects medications may have on different populations. “Many of the research studies [of medications] have been conducted [only] on white males,” Burnes Bolton points out. “It is very important when someone is prescribing a medication to know if that drug was tested on diverse populations. When reviewing the research, you must make sure you know what is the best evidence [about the drug’s effect on different populations].”
What Underwood finds disheartening is that even when a research study does include racially diverse participants, often the results are not analyzed by subgroups. “Inclusion [of minorities in a study] is not sufficient if one is not looking carefully at the outcomes of the research to determine whether or not there are similarities or differences for minorities, or nuances that need to be addressed in nursing practice,” she says.
Another factor that must be taken into account is the diversity that exists within a particular racial or ethnic group, Cantu advises. She says it’s critical for nurses to analyze the data and make sure there was a good research design in place. “Hispanics living on the U.S./Mexican border are going to be different than those living in an upscale suburban setting. You have to ask yourself: Is the population [in the study] similar to the one you treat? Where do they live? Do they have a high economic status? Do they have a low economic status? Make sure you are looking at evidence that pertains to your population.”
Where to Find Data
There are a number of ways to gather research data. Searching Internet databases is one of the fastest. Some of the best evidence-based health care databases include:
• The Cochrane Collaboration
• MEDLINE COS
• Cinahl Information Systems
• Agency for Healthcare Research and Quality (AHRQ)
There are also some databases and EBP online communities that focus specifically on minority health and health disparities, such as:
• American Public Health Association (APHA) Health Disparities Community Solutions Database
• National Minority Quality Forum
• Health Disparities Collaboratives
The Office of Minority Health Resource Center (OMHRC), the nation’s largest repository of information on minority health issues, provides free customized database searches on request. This service can be obtained by calling (800) 444-6472 or emailing the center at [email protected].
Another valuable source of data and best practices is other nurses—both researchers and clinicians. Burnes Bolton suggests tapping into the resources of professional nursing organizations, such as the American Academy of Nursing, for information. AAN initiatives such as Raise the Voice, which showcases the work of nurse “Edge Runners” who have created successful interventions and care models, may offer insights, she says.
Cantu suggests tapping into national and regional minority nursing associations. In addition, she says, many hospitals have clinical nurse specialists and nurse educators on their units. “They are a resource to go to. Schools of nursing are another place to use as an information resource. Maybe you can partner with them. Using these community resources is very appropriate and saves time for the bedside nurse.”
Sharing EBP Resources Online
Fisher has been working with the National Alaska Native American Indian Nurses Association (NANAINA), the Indian Health Service (IHS) and the NIH to create an online virtual community that helps promote the use of EBP to advance the agenda for reducing American Indian/Alaska Native health disparities. The online community links NANAINA faculty mentors with nurse clinicians at remote IHS sites and research staff from the NIH Clinical Center to collaborate and share resources in support of evidence-based projects.
According to Fisher, the virtual community grew out of a series of face-to-face meetings held in 2006-07 to establish relationships between the three collaborating organizations and to define evidence-based projects the nurses would work on. She says the Web-based community was launched last fall to provide technical support for the project’s mission and to enable the mentors and mentees to collaborate in an online environment.
“The virtual community provides a way to communicate and collaborate with the Indian Health Service nurses to promote evidence-based practice in their work settings,” Fisher explains. “The goal of the community was to provide a way for us to stay in touch following face-to-face meetings in order to continue our work.”
The online community includes such features as a discussion board, a resource center, a links section to help members quickly find Web-based information that will support their work, and opportunities for live chat or real-time meetings between two or more members.
Although the community is less than a year old, it has already accomplished a great deal, Fisher reports. “We were able to develop a list of members with contact information, share resources and develop posters for national presentation utilizing the virtual community—which would have otherwise been very difficult, since we [are all physically located in different parts] of the country. The virtual community has provided us with a means for staying connected.”
Filling Evidence Gaps
Another challenge that can arise when using EBP as a model of nursing care is: What do you do if the specific research data you need to answer your clinical question just isn’t out there—or at least not yet? Finding enough minority-inclusive research is just one part of the problem. Another obstacle, says Melnyk, is that it currently takes an average of 17 years for the findings of a study to become a valid, accepted part of the nursing literature.
“That [time lag] is a huge issue,” she emphasizes. “There are many areas in nursing where we do not yet have good evidence-based interventions to improve health outcomes. There are a lot of gaps in the evidence. That is why we need outstanding nurse researchers to generate evidence where we do not have it. Then we need outstanding clinicians to take the evidence that is generated and [apply evidence-based nursing skills] to translate it into clinical practice.”
One strategy for filling evidence gaps, Melnyk adds, is for nurses to generate practice-based evidence in their own clinical site by using outcome management. “Collect data through your chart records, do a certain practice and then look at outcomes and look at the data you have available,” she says. “The message I want to get out is that you do not have to be a rigorous researcher to be able to do outcome management and generate some evidence to guide your own practice in your [clinical] setting.”
This do-it-yourself approach to evidence generation can also be extremely helpful for busy nurses who might otherwise not have time to sit down at a computer and search for research data. “I think that many nurses, particularly bedside nurses, are so involved in patient care that they do not have the time to review on their own or attend meetings, workshops or seminars where evidence-based practice is discussed,” says Cantu.
Using EBP Effectively
Ellen Fineout-Overholt, PhD, RN, FNAP, director of the Center for the Advancement of Evidence-Based Practice at ASU College of Nursing, believes that having open communication with patients and colleagues plays a key role in providing evidence-based care.
“If I am taking care of a patient of color and do not know anything about that [person’s] culture, it is incumbent upon me to find out, to ask some questions,” she says. “Then it is incumbent on the patient to tell me, to talk to me. We need to have a dialogue so we can come to understand and know one another better to get the best outcome. Nurses need to [look at patients’ cultural beliefs and values] to see what they want and what they may need [in terms of care].”
That isn’t to say every outcome will be positive. Sometimes patients may not be willing to make a change in their behavior, especially if it goes against their belief system. “Then you need to tell them, ‘This is what the evidence says might happen. If you still want to go ahead [with that behavior], be informed of what your outcome may be,” Fineout-Overholt explains.
To use EBP effectively, she continues, nurses must always keep two things in mind: Why are we doing this and what outcome are we trying to achieve? “[Whatever you’re doing, whether it’s] inserting a Foley catheter into a bladder or holding a dying patient’s hand during a procedure, if you can keep those [two questions] as your focus it will really help you to understand what aspects [of the evidence] to put into practice. With hand-holding, culture . What does it mean to comfort someone in certain situations? With putting in a catheter, what you are trying to accomplish depends on what kind of circumstances there are. Keeping patient care front and center is imperative.”
Nurses should question the research data if it does not seem to fit in with their own clinical experiences, Cantu says. “We teach critical thinking [at our university]. In your experience, if you have seen something different, you cannot discount that. Then you may need to ask, ‘How do I get [these two pieces] to fit together?'”
Melnyk stresses that nurses need to work in a culture that supports EBP. “[Buy-in from] upper management is critical. Nurse managers and nurse executives need to understand EBP, practice it and create a culture that [encourages their nursing staff] to implement it. Part of that culture is having a cadre of It is critically important for nurses of color to be in the forefront of the evidence-based practice movement, Fisher emphasizes. “Minority nurses can help pave the way through modeling and dissemination of their EBP projects, which was the goal of our work with NANAINA and the Indian Health Service. It is exciting to see the nurses get involved with EBP and use their creativity to improve patient care. Once EBP becomes [more widely accepted] as a new way of practicing and providing care on a daily basis, both nurses and patients will benefit.”
Want to Learn More About EBP?
Join the (Journal) Club!
Two years ago, Pattie Soltero, BSN, RN, MAOM, operations manager for 6 North, a pediatric rehab and med-surg unit at Childrens Hospital Los Angeles, was looking for a way to help introduce the unit’s nursing staff to evidence-based practice (EBP). So she started a journal club. Journal clubs—also known as research clubs—are so called because they involve reading and discussing research studies published in clinical journals.
Soltero was introduced to the concept of EBP when she went to a professional conference. “There was a group of critical care nurses from a hospital here in L.A. who wanted to develop [a procedure for] providing their intubated patients with the best oral care possible,” she says. “So they went and researched the best mouthwash, the best toothbrush or utensil, and all the things related to providing the best oral care for intubated patients. Then they went to their manager and said, ‘These are the items we need.’ It turned out that the hospital already had a contract with a supplier that had every single item they needed. Based on that, they were able to develop a package for every single intubated patient in the ICU based on the evidence and their practice. Now [this hospital system] uses it in all of their facilities.”
The nursing staff on 6 North have varying levels of education, which is another reason Soltero started the journal club. “We have nurses with advanced degrees who are nurse practitioners and we have other nurses who have two-year associate’s degrees,” she explains. “Nurses with a two-year degree have had [little or no exposure to nursing research]. So we have taught them how to read a research article. We have taught them that nursing research is not something to be afraid of: It is done by nurses, it is not in a foreign language and it is applicable to our practice.”
Attend an EBP Conference Focusing on Vulnerable Populations WHEN:
February 19-20, 2009 WHAT:
10th Annual Evidence-Based Practice Conference: “Translating Research into Best Practice with Vulnerable Populations” WHERE:
Renaissance Glendale Hotel & Spa, Glendale, Ariz. SPONSORED BY:
Center for the Advancement of Evidence-Based Practice at Arizona State University College of Nursing & Healthcare Innovation FOR MORE INFORMATION:
Amy Fitzgerald, [email protected]
When the club first started, Soltero picked a research article once a month, posted it for everyone to read and then scheduled a meeting to discuss the study. “Little by little, after about six or seven months, some nurses started to really enjoy the journal club, so the staff [eventually took it over themselves],” she says. “Now it is just positive peer pressure [that motivates them to participate], so they meet on the weekend to do the journal club. I am not involved in it.”
While approximately 75% of the children the hospital treats are Hispanic, the facility also serves a variety of other ethnic communities. “We have an Armenian community close by and a Chinese community close by. And the rest of [our patient population] is a very diverse mix,” Soltero says.
She feels the journal club has been an excellent vehicle for implementing evidence-based practice to better meet the nursing needs of children of color. “For example, we looked at the spiritual care of our kids and how we are meeting those needs [given] the diversity of our population. People think because you are Hispanic you are Catholic, but that is not always true,” she notes. “We found a research article that focused on the spiritual care that was delivered to pediatric patients. Based on that, we were able to talk about how important that aspect is to their care.”
If you’re a nurse who wants to gain more insight into how a patient’s culture affects the care you provide, or a nursing educator who wants to enhance the cultural awareness, knowledge and skills of your students or nursing staff, the Culturally Competent Nursing Modules (CCNMs) online training program may be just the tool you need. And nurses who complete the free program can even earn continuing education credits.
A little more than a year old, the CCNMs are a case-based curriculum designed to help nurses better meet the cultural and linguistic needs of an increasingly multicultural patient population. According to 2000 U.S. Census data, Caucasians account for 75% of the country’s population, but that percentage is expected to drop to 47% by the year 2050 as the nation continues to attract immigrants, causing a dramatic shift in its cultural and ethnic diversity.
Created with support from the federal Office of Minority Health (OMH), the CCNMs were three years in the making. The curriculum’s development was guided by a National Project Advisory Committee comprised of nationally recognized experts on culturally competent nursing. In 2004, CCNM project staff conducted focus group sessions with practicing nurses in various specialties and geographic locations to obtain “real world” information that would help in developing the content and structure of the modules. In 2006, the CCNMs were pilot tested in seven health care organizations across the country. Based on feedback from those tests, the modules underwent minor revisions and were officially launched in 2007, under the title “Culturally Competent Nursing Care: A Cornerstone of Caring.”
“The Culturally Competent Nursing Models are designed to provide some tools for improving cultural competence, and these tools should be incorporated into one’s daily practices and expanded upon over time,” says Ann S. Kenny, MPH, BSN, RN, project director for the CCNMs. “Keep in mind that even the most culturally competent individual can still make cultural mistakes. However, the more culturally competent one is, the easier it should be to right a situation where a cultural mistake has occurred.”
The training program consists of an introduction followed by three modules (courses) that can be taken together or separately (see sidebar on page TK). The content is based on the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care, which were issued by OMH in 2000. The 14 CLAS standards–which cover culturally competent care, language access services and organizational supports– are designed to provide health care facilities with guidelines for “improving the health of racial and ethnic minority populations through the development of effective health policies and programs that help to eliminate disparities in health care.”
The CCNMs’ content is presented in an interactive, Web-based format. It includes such features as streaming-video case study vignettes that depict realistic patient/provider scenarios, and “stories from the front lines” from actual nurses. There are also short, user-friendly sections entitled “Fast Facts,” “Cultural Insights” and “Pulse Points.” All of these features are designed to hold users’ interest and reinforce the learning points, Kenny notes.
In addition to the online self-study format, the CCNMs are also available as a DVD featuring the case studies, which works better in group settings such as nursing school classrooms and hospital staff-training sessions. “The majority of users do complete the program in the online version, because it is convenient for busy nurses to start and stop as their schedule permits,” says Kenny. “The online program allows users to complete the courses anytime and anywhere.”
As of this past April, there were more than 7,000 registered users working on the CCNMs. More than 3,000 participants have completed the first module, nearly 2,000 have finished the second course and more than 1,500 have completed the third one.
A nurse can earn a total of nine continuing education units (CEUs) for completing the curriculum: three CEUs per module. To receive credit, users must also complete a pre-test, a post-test (with a score of 70% or better) and the course evaluation. The pre- and post-test are designed to measure the participant’s knowledge of the material presented in the course, explains Kenny.
The CCNMs are accredited for continuing education by the American Nurses Credentialing Center and the National Association of Social Workers. As of April, nearly 6,000 nurses and more than 300 social workers have received CEUs from the program. Almost 1,200 Statement of Participation certificates have been awarded.
Something for Everybody
What kinds of nurses are taking the Culturally Competent Nursing Modules and in what kinds of settings? The majority of CCNM users are nurses working in hospitals, says Kenny. Students and health educators comprise the largest portion of this group, followed by nurses working in public/community health, psychiatric/mental health, medical-surgical nursing and pediatrics. Most users work in urban locations, followed by suburban and rural areas. A few users worked in multiple practice settings or in a military facility.
As for the demographic breakdown, 92% of nurses who are taking the courses are female and 74.5% are non-Hispanic whites. Age-wise, the majority of participants are between the ages of 45 and 55 years old.
Many health care insurance companies, such as Aetna, Humana and Blue Cross Blue Shield, are using the CCNMs to train their nurses, adds Kenny.
“We have also been approached by several educators, such as nursing school professors, who are interested in incorporating the course into their current ethics or cultural competency training,” she continues. “They typically have their students register for and complete the online program, then submit their certificates as proof of completion.” Other nursing faculty are using the modules as extra-credit options for students.
CCNMs in the Classroom
Before Mary K. Kirkpatrick, EdD, MSN, RN, professor and international coordinator at East Carolina University College of Nursing in Greenville, N.C., assigned the CCNMs to her students, she took them herself. Kirkpatrick was so impressed with the modules that she incorporated parts of them into two of her courses. One of the courses focuses on globalization and health care; the other addresses chronic illness.
What the Course CoversThe Culturally Competent Nursing Modules training program is divided into three modules (courses). The modules are organized around the three themes of the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health Care: culturally competent care (standards 1-3), language access services (standards 4-7) and organizational supports (standards 8-14).Course I: Delivering Culturally Competent Nursing Care
Knowledge-centered and fact-centered approaches
Course II: Using Language Access Services
Triadic interview process
Health literacy and translated materials
Course III: Supporting and Advocating for Culturally Competent Health Care Organizations
“Globalization begins with becoming culturally competent,” she says. “And cultural competence sets the stage for the remainder of the chronic illness course.” The CCNMs will count for 10% of the students’ graded work.
Beginning this August, Kirkpatrick will incorporate the CCNMs into the nursing school’s orientation program. She plans to assign students to take the course as a self-directed learning experience during the orientation process.
“I like several things about the CCNM course,” she says. “First, it is comprehensive with a strong conceptual, theoretical basis. Secondly, I like how interactive it is with the videos and case studies. It is visually appealing and has an evaluative component for each module.”
Kirkpatrick believes it is an effective teaching tool because it appeals to a variety of learning styles. “The adopted strategies and models, as well as videos and case studies, were excellent,” she adds. “The course provides [students] with the opportunity to gain knowledge of these concepts [and then] apply the concepts to several different [population] groups.”
To assist nurse educators and staff trainers in leading group sessions of the CCNMs, Kenny and her team are currently developing a Facilitator’s Toolkit. The toolkit includes a DVD of case studies and a CD with PowerPoint slides. It also has a facilitator’s guide and an iDVD site, which is supplemental to the CCNMs. The guide and iDVD site are currently undergoing pilot testing and the toolkit is tentatively scheduled for release this summer.
Also in the works are a facilitators’ administrative site and corresponding participant site, which will enable facilitator participants to receive continuing education credit for completing the course. Any registered nurse can become a facilitator upon successfully completing the CCNMs, Kenny says.
Nurses and students who have completed the modules have nothing but praise for them. Overall, the program has been well received by the nursing community and has been endorsed by Rebecca Patton, MSN, RN, CNOR, the current president of the American Nurses Association (ANA), Kenny reports.
What You’ll LearnAfter completing the Culturally Competent Nursing Modules, nurses should be able to:
Define issues related to cultural competency in nursing practice.
Identify strategies to promote self-awareness about attitudes, beliefs, biases and behaviors that may influence the nursing care they provide.
Devise strategies to enhance skills toward the provision of culturally competent nursing care.
Demonstrate the advantages of the adoption of the CLAS standards as appropriate in their nursing practice.
“We have received a lot of positive feedback about the course,” she adds. “Ninety-five percent of the participants who completed the modules indicated that they would recommend the program to their colleagues.” Many nurse educators tell Kenny that the availability of the modules has saved them from having to develop a whole new curriculum.
“User-friendly,” “interesting” and “informative” are common phrases participants have used to describe the course.
“It enabled me to understand how to relate to patients of different cultures, especially how to communicate with them and handle any problems or medical needs they may have,” says Shannon Harper, BSN, RN, an African American nursing student at Valdosta State University in Valdosta, Georgia. Harper completed the CCNMs as a requirement for a med-surg nursing course this spring. Prior to that, he did not know of any courses focusing on cultural competence being offered to nursing students.
Nurses should be required to be trained in cultural competency, says Abel Rodriguez, RN, CCM, who went back to nursing school at Miami Dade College part time to obtain a BSN. Like Harper, he took the modules as part of a class assignment. “The course made me aware of the need for nurses to become culturally competent because it impacts the quality and outcomes of patient care.”
Jackson Memorial Hospital in Miami, where Rodriguez has worked for the past nine years, serves a highly diverse community, including immigrants from the Caribbean, Latin America, Asia and Europe. “Nurses have to be aware of patients’ cultural backgrounds because different cultures value things differently,” says Rodriguez, who is of Afro-Cuban descent. “Those cultural nuances, habits and mores have an impact on patients and their families.”
Although the CCNMs can serve as a stand-alone educational tool, nurses shouldn’t stop there for their cultural competency training, Kenny emphasizes. “Increasing one’s cultural competence is a continual process and can always be built upon by combining multiple learning experiences and training programs.”
One such program is the OMH’s newest initiative, the Culturally Competent Curriculum for Disaster Preparedness and Crisis Response, which is currently being developed. Its purpose is to equip first responders with the knowledge, awareness and skills needed to provide emergency health care services to racially and ethnically diverse populations during times of disaster, says Kenny. This course, which may be of particular interest to nurses working in emergency situations or environments, is scheduled to launch in spring 2009.
For advanced practice nurses, there are the Cultural Competency Curriculum Modules, which have been available since 2003. Although these modules are geared toward doctors—the actual course title is “A Physician’s Practical Guide to Culturally Competent Care”—they also carry accreditation for nurse practitioners.
Whichever course (or courses) nurses choose to take, there’s no question that the end result will be better patient care. As ANA President Patton states in the introduction to the CCNM facilitator’s DVD, “By practicing culturally competent care, nurses will integrate the needs and values of all persons in their professional relationships and help to reduce racial and ethnic disparities in health care.”
For more information about the Culturally Competent Nursing Modules, visit www.thinkculturalhealth.org.
In recent years, nursing schools throughout the country have gone to great lengths to recruit more students from populations that have been traditionally underrepresented in the profession: racial and ethnic minorities, men, people with disabilities and older, “nontraditional” students. But despite this growing emphasis on diversity, that doesn’t mean these students always find a welcoming environment in the classroom where, ironically, they are taught one of the most nurturing of professions.
Today, of course, it is illegal to intentionally deny anyone admission to a college or university on the basis of race, religion, gender, disability or similar factors. And in our politically correct society, minority nursing students rarely hear racial or ethnic slurs from instructors, staff or fellow students. But even though such blatant forms of discrimination are pretty much a thing of the past, students whose race, gender, disability, etc. causes them to be perceived as different from the majority student population may still find themselves feeling acutely aware of their “differentness.”
G. Rumay Alexander, EdD, RN
For instance, they may have feelings of isolation, of being “shut out” by other students or of being “tolerated” rather than accepted. (See “What Students Say.”) In some cases, they may feel they are being treated differently than other students, or even that they are being singled out or picked on by an instructor for no apparent reason. At its worst, this situation can result in complaints–whether real or perceived–of minority students being held to different standards than their majority counterparts–e.g., given more or different assignments, undeservedly low grades on tests, less opportunity to rewrite a paper or harsher treatment when it comes to absences and make-up work.
“Some students just feel targeted. They don’t fit the image of what the faculty think a nurse should be,” says Sheldon Fields, PhD, RN, APRN, BC, FNP, AACRN, assistant professor at the University of Rochester School of Nursing in Rochester, N.Y. “Maybe you have a different cultural background, language, skin color or gender; maybe you’re a little older or younger, or maybe you’re out about being lesbian or gay. [Whatever it is, it makes you stand out and] it can make you a [potential] target.”
A Subtler Form of Bias
“Discrimination in nursing schools is becoming less of a problem, that’s the good news,” says Chad O’Lynn, PhD, RN, an instructor at the University of Portland School of Nursing in Oregon and author of the forthcoming book Men in Nursing: History, Challenges and Opportunities. “But when it is present, it’s more covert.”
Courageous Dialogues: Teaching Faculty and Staff to Embrace Diversity During orientation at the University of North Carolina at Chapel Hill School of Nursing, students first hear from the dean. Then they hear from G. Rumay Alexander, EdD, RN, director of the school’s Office of Multicultural Affairs. During her one-hour lecture on diversity, Alexander makes it clear that the school’s policy is zero tolerance for any type of discrimination or harassment against anyone. “If it does happen to you, you have a place to bring [your complaint] where your perspective will be respected,” she says.But students aren’t the only ones to hear from Alexander, who is one of a growing number of chief diversity officers being hired by nursing schools in the past few years. Three times a year, she leads what she calls “courageous dialogues” for faculty and staff, whose attendance is mandatory. Prior to the session, they are assigned to read one of three provocative articles. “The articles address general topics that help us move toward understanding each other better,” she says. Last year, the conversations focused on the phenomenon of “white privilege”– how it operates and what it confers upon people both in the majority and the minority. “Being white is a race,” Alexander explains. “But it’s invisible because it’s considered the norm in this country. Out of that norm comes a privilege and acceptance. If you don’t fit the norm, you have a different experience.” These conversations address how individuals can keep their own values and beliefs yet also understand another person’s perspective, says Alexander, who defines diversity as “holding multiple perspectives without judgment.” People can learn how to do this by spending time with others who are different from themselves, traveling to foreign countries and learning about different cultures and religions, she adds.Because faculty and staff spend so much time together, it’s essential that they understand each other, Alexander maintains. And this need to understand and accept other people’s differences is even more important in the teacher-student relationship. “Faculty have a multitude of students coming from all walks of life,” she says. “Helping them develop awareness through conscientious conversation empowers them to handle all kinds of situations in their classrooms“The purpose of this program is not to point a finger at culturally illiterate people,” Alexander concludes, “but rather to raise the level of awareness, make positive changes for an inclusive world and prepare nurses who can take care of a variety of patients.”
While he still hears stories of overt discrimination from male nursing students–like the one about a professor who said, “I’ve never passed a male student and you aren’t going to pass either”–O’Lynn believes these situations are happening less frequently these days. They are being replaced, however, by a more subtle bias that manifests itself in a learning environment that doesn’t recognize the strengths and talents that ethnic minority and male students bring to the profession, he says.
“The nursing profession is still teaching students how to care for patients in one way,” O’Lynn argues. “The underlying message [to male students] is that if you want to be a nurse, you have to behave like a woman. Although that message isn’t stated explicitly, it is often implicit.” For example, he says, men communicate differently than women and the male style of communication is not valued in nursing schools.
Furthermore, O’Lynn feels there is an overall lack of sensitivity to the issues and concerns that male nursing students face–or even to the fact that male students are present at all. There is the constant referral to nurses as “she,” not only in lectures but in textbooks, he points out. There is the lack of curriculum content concerning men’s health issues, although numerous courses are taught on women’s health.
As a board member of the American Assembly for Men in Nursing, O’Lynn says he hears from many male students who are nervous about examining female patients, particularly in sensitive areas, because they’re afraid of being accused of sexually inappropriate touching. Here, too, he feels that nursing educators are not acknowledging the needs of male students, let alone addressing them.
“It’s the elephant in the living room that nobody talks about,” O’Lynn maintains, adding that nursing programs must do more to help male students learn to work through these issues.
Susan Fleming, MN, RN, a nursing clinical instructor/lecturer at Washington State University’s Intercollegiate College of Nursing in Spokane and a board member of ExceptionalNurse.com, an online resource for nurses with disabilities, agrees that there is less discrimination nowadays than when she first started her nursing studies, but that it does still exist. Fleming was born without a left hand and was denied admission to the first nursing school she applied to because of her disability. She was subsequently accepted at a different school and completed the program successfully.
“[Today] it’s usually an instructor or group of instructors who can’t see past a student’s disability,” she says. “They usually have a problem with [the student’s ability to perform] one skill and they focus [all their attention] on that.”
Fields believes that one reason why bias still occurs in nursing schools today is that even though the students have become more diverse, the nursing faculty has remained virtually unchanged. They are still predominantly white and female. “The nursing faculty hasn’t changed, they’ve just gotten older,” he says. “They’re not adding enough diversity to the workforce to make a difference.”
Some diversity experts argue that it’s unfair to place all of the blame on a few insensitive faculty. “It’s not so much individual acts that people do,” says G. Rumay Alexander, EdD, RN, director of the Office of Multicultural Affairs at the University of North Carolina at Chapel Hill School of Nursing. “It’s systemic. Any ‘ism,’ whether it be racism, sexism, or ageism, can only operate if the system perpetuates it.”
Take admissions policies, for example. Alexander believes many nursing schools have admissions criteria that, while not deliberately exclusionary, may unintentionally be creating an unequal playing field for applicants from underrepresented populations.
“Admissions committees struggle with how to meet mandates in the [institution’s] vision and mission statements to meet the demand of a demographically changed world,” notes Alexander, who also is an associate clinical professor in the School of Nursing. Although nursing schools are incorporating these ideas into their public statements, they aren’t necessarily living them out, she believes. While the intent in many nursing schools today is to be inclusive and have a diverse student body, admissions committees are often operating from outdated guidelines that can actually achieve the opposite effect.
What the schools value or give credit for in their admissions policies can inadvertently keep certain students out, and even perpetuate past discrimination without the school being fully aware of it. For instance, says Alexander, the purpose of promoting legacy is to reward the alumni, but an unintended consequence is excluding students from populations that weren’t accepted in the past. “You can’t have a legacy if [your parents were denied admission],” she points out. Rather than doing away with legacy, she suggests that schools can add an admissions policy that rewards individuals who are the first generation in their family to attend nursing school.
Another issue is how nursing schools define leadership for admissions purposes. Typically, schools value individuals who have demonstrated leadership roles, such as serving as president of the class or a sorority. Many students of color may not have had those opportunities, but they may have served as president of their church choir. “Cultures can have their own ways of crafting a leader,” says Alexander. “To be fair, you need to expand the definition.”
Admissions essays can be still another source of unintended bias. Writing styles may be influenced by a student’s culture, Alexander explains. For example, if the faculty is subconsciously biased toward essays that display emotion about why the student wants to enter the nursing profession, a minority student from a culture that is stoic about expressing emotion would be at a disadvantage.
Conversely, if the admissions committee looks for how knowledgeable about the profession the applicant is and he or she comes from a culture that emphasizes story- telling, that student may be penalized on the essay, says Maria Warda, PhD, RN, dean of nursing at Georgia Southwestern State University.
Admissions criteria that don’t give applicants credit for being multicultural or bilingual also can be inadvertently exclusionary, adds Warda, who is vice president of the National Association of Hispanic Nurses. She notes that current admissions standards are predominantly qualitative, focusing on measurements such as grade point averages and SAT scores. She recommends using admissions criteria that focus on a combination of quantitative and qualitative measures.
Problem or Perception?
Antiquated admissions policies that fail to acknowledge cultural differences can result in bias against minority students before they even get into a nursing program. But what if you are a current nursing student and you feel that you’re experiencing unequal treatment because of your race, ethnicity, gender, religion, disability, sexual orientation, age, etc.? Should you turn the other cheek and just try to focus all your attention on your studies? Or should you speak up about it?
Obviously, it’s hard to just ignore the situation if you feel it is jeopardizing your chances of passing the course, getting a good grade or graduating from the program. Most of the experts interviewed for this article agree that students who believe they have been discriminated against–whether by a faculty member, administrator, clinical instructor or another student–should discuss the situation with the individual involved.
What Students SayA sampling of student comments posted on the MinorityNurse.com Discussion Forum or emailed to the editor of Minority Nurse: “I would like to know how other students deal with being the only black student in the class. I feel so frustrated with the way they just close me out. They make me feel like I have no business being in this profession.” “I was recently referred to as ‘the black girl’ by the teacher in front of 47 other nursing students. I am one of five minority students in the class (two African Americans, two Africans and one Hispanic). How do nursing schools plan to encourage minorities to enroll and complete the program when discrimination is experienced within the program?”“I am a current nursing student being pressured to quit the program by people who don’t even know my abilities. Should I have to quit because I am missing my left arm? I am not considered legally disabled, so why should I have to quit school? I have a prosthetic arm and I can do practically anything. The faculty and assistant dean tell me I need to quit now or risk an F on my transcripts. They even offered to give back 65% of my tuition if I quit now! Nursing is my dream and it’s being squashed. Please help!”–Compiled by Pam Chwedyk
But before you initiate that discussion, you must do what psychotherapists refer to as “reality testing.” In other words, is it really discrimination or is it just your perception? Is there a possibility that you’re being oversensitive? Could you have misinterpreted or overpersonalized the individual’s comments or actions?
Alexander recommends writing down the incident as soon as it happens. “Record it immediately while the details are still fresh,” she says. Then you should process it past someone you trust to get another perspective.
Minority or male students may feel more comfortable checking their perceptions by talking to a student or faculty member of their same race, ethnicity or gender. If that is not possible within the nursing department, O’Lynn suggests seeking out a minority or male professor from another academic department.
He also offers this rule of thumb for assessing whether or not a male student is really experiencing gender bias: If the roles were reversed and the situation happened to a female student in medical school and it would be considered a problem, then it’s a problem for the male nursing student and he is not being overly sensitive.
Taking Action. . .
If a student’s perception of bias is validated, it’s time to proceed with what Alexander refers to as a “courageous dialogue.” As her nursing school’s chief diversity officer, helping to resolve such conflicts is part of her job. “I help people work through it, rather than walk away and make assumptions or judgments and operate out of those for the remainder of their time together,” she says.
If students feel that they can’t approach the faculty member because of the power inequity, they come to her. If the student feels threatened or vulnerable, Alexander suggests having a third party sit in on the discussion, as these types of situations can escalate rapidly. Over the years, she has served as that third party on behalf of students as well as faculty and staff members. “I’m there to support that person who has experienced the inequity, unfairness or injustice,” she says. In certain situations, she has even interviewed other students who were present during the incident.
Susan Fleming, MN, RN
Alexander not only encourages students to pursue this dialogue, she also offers tips on how to communicate their position more effectively. For example, she says, always use “I” statements, as in “I felt this way. . . .” Using “you” statements, such as “you make me feel. . .,” puts the other person on the defensive.
If talking one-on-one doesn’t solve the problem, then the student should learn the school’s policies and procedures for filing a grievance. “The more you adhere to the process, the better the chance of having your voice heard,” Warda advises.
Following the chain of command may involve talking to the school’s diversity officer, the student’s advisor or the associate dean. At most schools, the academic dean or the director of the Office of Admissions are helpful when trying to work through these types of situations, says Alexander. Talking with a representative of your school’s student nursing organization or minority student association who can share the encounter with leadership may also be beneficial.
Additionally, most schools have an Equal Opportunity office to mediate conflicts regarding discrimination and harassment. Fields encourages students to seek out an ombudsman, a process that he has found to be helpful because it gives access to an outside person who is unbiased.
Students who feel they have not gotten satisfaction from their school’s grievance process can seek outside legal counsel, provided that they have ample documentation to prove their case. Asking national organizations, such as the National Black Nurses Association, the National Association of Hispanic Nurses or the American Assembly for Men in Nursing, to intercede on your behalf may also be an option. However, the decision to take action at this level should be weighed heavily because it does come with potentially steep consequences.
“The problem is that nursing courses are not transferred between schools, so the student could be throwing away an entire academic year or two,” Warda cautions. Or worse, you could be jeopardizing your future career in nursing.
. . .Or Not
Sometimes you really can fight City Hall. Other times the battle may just not be winnable and it’s better to drop it and move on. Ultimately, minority nursing students who feel they are victims of bias must decide which option is right for them.
Alexander notes that not all schools jump to embrace diversity. Some talk about it, but don’t actually do it. “You have to decide ultimately if this school is the right place for you,” she says. “If you’re under physical and mental distress, getting sick all the time, then these are signals that it’s not the best place for you.”
If the situation is so egregious that it’s threatening your ability to progress, then you must stand up for yourself and take action, says Fields. If, on the other hand, the situation is not that bad and you have some support to help you handle it, then “suck it up, graduate and move on with your life,” he advises.
“At some point in your career, you will be able to express how you feel by, for example, never giving back to your alma mater,” Fields continues. “You live to fight another day. You don’t jeopardize your goals, especially if you’re outnumbered or outgunned. Nursing school is hard enough without having to deal with that burden.”
Fleming’s case is a perfect example. When she first applied to nursing school she was given a “skills test” that involved spiking IV bottles. Because she had some difficulty performing the task–which was not surprising, since she had never been taught how to do it–she was told that she would endanger patients’ lives and she was not accepted into the program. Continuing to work as a nurses’ aide and encouraged by a doctor to re-apply to other nursing schools, Fleming found a school that welcomed her. When she asked about the “skills test,” she was told that giving her such a test would be illegal. In hindsight, Fleming realizes that half of her current students wouldn’t have been able to pass the test.
“I realized that I could expend my energy fighting the system,” she says. “But because I found another school that did accept me, I thought it was more important to turn my energy to my education.
“There are no stop signs,” she adds. “They’re just roadblocks. You have to go around them.”
Above all, says Fields, “Never give up your dream of being a nurse just because one particular school doesn’t think you fit its mold for the kind of nurse it wants to produce.”
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