19Jones Leadership(F)-ch 19 1/14/07 3:51 PM Page 323 Nursing Celebrates Cultural Diversity Box 19-3 Sociocultural Self Assessment Directions: Use your answers to help yourself have a better understanding of your own cultural and social beliefs What is my cultural heritage? Which ethnic groups I belong to? My age group? My religious affiliation? My socioeconomic status? Do I assume that others have the same values and beliefs that I have? What type of contact have I had with persons from different backgrounds? Do I assume that other people have the same values and beliefs that I have? What group affiliations am I proud of? Are my attitudes and behavior ethnocentric? What would I change about my group affiliations, if I could? Why? Have I ever felt rejected by another group? Did this experience make me more sensitive to other cultures or cause me to vilify others who were different from myself? Did I get messages about people who were different from me from family and friends? Have these attitudes influenced my opinions today? What are the main biases I have about individuals from different cultures? Do these stereotypes impede me from developing cultural sensitivity? What attitudes I need to change within myself in order to work effectively with individuals from other cultures? Text/image rights not available Chitty, K.K Illness and culture: Impact on patients, families and nurses (2005) In Professional Nursing: Concepts & Challenges, St Louis: Elsevier, p 468 should pose their responses to such situations in a holistic way Effective nursing practice recognizes that there is a need to adopt nonjudgmental attitudes toward patients’ religious beliefs in order to avoid conflicts and confrontation It is important for caregivers to diffuse any emotions by providing respect, support, and understanding for the family’s religious beliefs, even if they are contrary to their own (Grube, et al., 1994) In considering end-of-life decision making, cultural values and spirituality may be even more important Elderly clients who are dying may find their values in direct conflict with those of hospital staff Collaboration and cooperation are key components to ensure that patients receive optimal health care When end-of-life issues arise, there may be a conflict between the physician’s and/or nurse’s own 323 personal religious beliefs and the desire to placate the wishes of the family This can occur even though the patient has a living will on file in his chart The physician’s values in turn may create an ethical dilemma, which could result in stressful working conditions for the nursing staff Subsequently, this creates a conflict between the nursing staff’s value system and the institution’s practices in honoring the patient’s advance directives In the face of any conflict, however, Leininger (1997) describes a culturally competent nurse as one who demonstrates the following skills and attributes: Uses nursing concepts, principles, and avail- able research findings to assess and guide practices Understands and values the cultural beliefs and practices of designated cultures so that nursing care is adapted to meet that individual client’s needs in a meaningful way Knows how to avoid and prevent major cultural conflicts, clashes, or hurtful care practices Demonstrates the confidence to be able to work effectively and knowingly with clients from different cultures and is also able to evaluate transcultural nursing care outcomes When clients have received culturally based nursing care, they exhibit signs of satisfaction, are pleased with the cultural accommodations that have been made for them, and praise their overall care Managing a Culturally Diverse Workforce It is important for nurse managers to approach every staff person as an individual when directing a diverse team of health-care workers Staff members, like clients, may be diverse in values, beliefs, and mannerisms But they have many things in common They want to succeed in their jobs and be accepted by others (Blank & Slipp, 1994) Nurse managers hold the key to expose the full potential of each person on the staff and should openly support the contributions and competencies of staff members from all cultural groups Husting (1995) believes that management has a responsibility to address cultural issues because of the rapidly chang- 19Jones Leadership(F)-ch 19 324 1/14/07 3:51 PM Page 324 Skills for Being an Effective Manager hot topic: Recruitment of Foreign Nurses Delivery of high-quality health care in our multicultural society will continue to be a challenge for many hospitals, especially with the present nursing shortage in the United States Due to the inability of the workforce to keep pace with the demands for more health-care providers, many health-care facilities are recruiting nurses from other countries such as Canada, Ireland, Great Britain, and the Philippines The U.S Bureau of Labor Statistics (BLS) (1998) has projected that nursing, the largest health-care occupation, will grow faster than average for all occupations in the next decade Already, the U.S government has relaxed rules allowing temporary work visas for Canadian and Mexican nurses who qualify There are also provisions for allowing nurses educated in other English-speaking countries to work in the United States without taking the licensing examination Some countries, such as the Philippines, train more nurses than they can use, so some believe that hospitals in this country should be permitted to recruit them The nursing shortage dilemma will continue to generate many arguments both for and against importing foreign nurses Meanwhile, as the United States continues to be a melting pot of many nations, a culturally diverse nursing workforce is a reality despite being intentionally ignored in many parts of the United States or being given rhetorical “lip service.” Nursing will need to implement strategies to reflect the cultural mix of society more closely Recommendations from the American Academy of Nursing expert panel on cultural competence include recruitment and retention of a diverse workforce (Meleis et al, 1995) Strategies include mentoring by same-culture minorities together with workshops, continuing education programs, and the use of consultants who are trained to promote culturally competent care ing health-care workforce Diversity of values and beliefs can create conflict and result in a work environment that is not conducive to worker effectiveness and quality client care One alternative Husting proposes is to create equal worker partnerships that capitalize on the best aspects of all cultures for an effective, harmonious work setting She suggests that this can be accomplished by discussing cultural viewpoints as a part of decision making and acknowledging and respecting differing cultures, such as rotating the chairing of staff meetings to ensure equal participation and access to the agenda This approach, Husting states, eliminates one-way communication within the work group and encourages alternative points of view and group discussion while enhancing the concept of shared governance Managing one’s own personal thinking and assisting coworkers to think in innovative ways are part of the leading and management role in cultural diversity Management of issues that involve culture, whether gender, religious, ethnic, or any other kind, requires patience, persistence, and a great deal of understanding When the workforce includes nurses who speak English as a second language, the nurse manager needs to carefully evaluate the communication systems that are in use along with the manner in which messages are communicated Slowly repeating instructions may be necessary to ensure comprehension and understanding of what is required Culturally skilled nurse managers can provide cultural safety to patients by making sure that messages about patient care are received and understood This might be accomplished by sitting down with the staff nurse and analyzing the situation to make sure that understanding has occurred In addition, the nurse manager might use a communication notebook that allows the nurse to slowly “understand” information by writing down ideas that may appear to be unclear By addressing cultural diversity directly, the nurse manager is offsetting future negative effects on performance and staff interactions (Meleis, et al., 1995) Sullivan and Decker (2001) described the importance of communication and how cultural beliefs, attitudes, and behavior affect communication Gestures, verbal tone, body movements, and physical closeness when communicating are all part of a person’s culture For the nurse manager, understanding these cultural behaviors is imperative in accomplishing effective communication within the workforce population Tappen (2001) addressed differences across cultures that the nurse manager needs to monitor These differences include spatial differences, relationships to people in authority, eye contact, expressions of feelings, thinking modes, meanings in different languages, evidence-based decision making, and preferred leadership/management style Nurses need to ensure that effective communication by staff with clients and others does not lead to misunderstandings and eventual alienation Nurse managers must also work with their staff to foster respect for different lifestyles 19Jones Leadership(F)-ch 19 1/14/07 3:51 PM Page 325 Nursing Celebrates Cultural Diversity The complexities of culture strongly influence opinions, perceptions, and generalizations Mancini (1997) wrote about the need for supervisors and nurse managers to be vigilant about attitudes and behaviors that encourage ethnic or racial stereotypes and that inhibit trust and communication Managers can help eliminate stereotyping by presenting alternative views or referring to lists of commonalities among the staff Mancini believes that a culturally skilled manager who understands and values differences can build trust and enhance communication, motivation, and production in a team Ultimately, experience working with a diverse staff may be the best educational environment for learning about different cultures Lowenstein and Glanville (1996) challenge nurse managers to use their leadership positions to address communication and motivational issues when working with nurses from other cultures They recommend that cultural conflicts be confronted and effective resolutions be reached One example is that staff members may be reluctant to admit language problems that hamper their written communication Unit-oriented workshops arranged by the nurse manager, together with effective mentoring by nurses trained in cross-cultural care, can result in quality care outcomes Andrews (1998) reported on the increasingly more diverse workforce in the United States She advocated development of a transcultural nursing administration She advocated that if nursing administrators are committed to transcultural management, they should actively promote recruitment of diverse staff members and be alert to any signs of prejudice in their organization Likewise, mission statements and policies should be reviewed to reflect workforce diversity All Good Things One must remember that in a multicultural society as diverse as the United States, health care cannot come in one form only to fit the needs of everyone Culture has a powerful influence on the type of health care that is both delivered and sought by clients Population demographic projections in the United States show dramatic changes in ethnicity and age groups All individuals have the need to be accepted by their health-care providers and have 325 Practice to Strive For 19-1 The nurse manager needs to employ strong cultural competence initiatives in order to be an effective leader in today’s workplace environment Cultural competence is illustrated by cultural assessment, planning, and familiarity with and respect for various traditional healing systems and beliefs Time should be taken to get to know and understand one’s colleagues, which facilitates learning about their ethnic and cultural heritages and assists in building trust and confidence in the leadership and management of the unit Planning workshops in cultural sensitivity to discuss issues on cultural diversity can motivate others toward culturally competent communication and ultimately leads others toward cultural competence in their own nursing practice Integrating cultural diversity into the workplace and successfully organizing teams that include culturally diverse workers are key to providing effective role models and mentors on the unit Treating all staff members equally and with patience can provide them with a feeling of value, respect, and dignity All of these techniques are essential for enhancing, maintaining, and retaining culturally diverse professionals in today’s workforce (Office of Minority Health, 2000) their cultural interpretations of health acknowledged and respected Nurses have always accepted the concept of holistic health care, more than any other group in the health profession Transcultural nursing provides a theoretical base for nursing regarding cultural competence Nursing also needs to implement effective strategies to reflect the cultural mix of society within the workforce Thus, with increased knowledge, sensitivity, respect, and understanding, nurses can provide the highest quality of health care for clients in our multicultural society This chapter has presented several models, tools, and techniques for meeting the health-care needs of an increasingly diverse population Understanding cultural diversity and its impact on effective healthcare delivery requires a commitment on the part of all health-care providers The chapter has also provided information to assist nurse leaders in providing effective management of a culturally diverse workforce It emphasized the importance of creating a culturally sensitive work environment Nurses need to stay abreast of major population shifts in the United States and be prepared to manage diversity effectively in order to be competent health-care providers 19Jones Leadership(F)-ch 19 326 1/14/07 3:51 PM Page 326 Skills for Being an Effective Manager Let’s Talk Think of a patient you have cared for from another culture Did you perceive you were able to communicate effectively with the patient? Did you believe the patient understood all aspects of the care being provided? What did you to facilitate the care of your patient? Think of a foreign nurse with whom you have worked Did you and your coworkers accept this nurse? Was this nurse incorporated into the “team” willingly? Did you have trouble understanding the nurse’s accent? Think of the nurse manager on this unit How did the manager help the foreign nurse assimilate into the unit’s culture? Were workshops conducted to assist the staff in understanding some of the cultural differences? How did the manager promote acceptance of this foreign nurse by the other team members? NCLEX Questions Culture is: A Shared values, behaviors, and beliefs that are reinforced through social interactions B Specific only to the individual C Transmitted from one generation to the next D A and C Levels of culture that have been identified by Schein (1985) include: A The visible level; this includes physical space and social environment; for example, the image that is projected at first encounter B The values; this includes the nurse’s personal value system C Traditions; this includes behavior based on ones’ ethnicity D B and C Leininger (1991) is credited with developing a theory of culture care that includes: A The ideas that cultural constructs are embedded in each other and that their application is both broad and holistic B Influencers that are not causal or linear relationships C An open world or an open system of living reflective of the natural world of most humans D All of the above Transculturism describes a nurse who: A Is grounded in his or her own culture B Has the skills to be able to work in a multicultural environment C Works with more than one culture D A and B A cultural assessment involves: A Asking people their preferences B A detailed description of the patient’s ethnicity C A description of the traditions to which a patient ascribes D All of the above Leininger’s domains to review when conducting a cultural assessment include all of the following EXCEPT: A Bowel and bladder patterns B Cultural norms and values C Cultural taboos and myths D Ethnocentric tendencies and worldviews Leininger describes a culturally competent nurse as one who demonstrates all of the following skills and attributes EXCEPT: A Uses nursing concepts, principles, and available research findings to assess and guide practices B Understands and values the cultural beliefs and practices of designated cultures so that nursing care is adapted to meet that individual client’s needs in a meaningful way C Knows how to avoid and prevent major cultural conflicts, clashes, or hurtful care practices D Demonstrates use of the nursing process to work effectively and knowingly with the client Spirituality is defined as: A One’s religious preference B Each person’s unique life experience and one’s personal effort to find purpose and meaning in life C Believing in a supreme being D All of the above 19Jones Leadership(F)-ch 19 1/14/07 3:51 PM Page 327 Nursing Celebrates Cultural Diversity Cultural diversity is defined as: A When a nurse cares for patients from different backgrounds B A hospital with patient demographics from different ethnicities C Differences in race, ethnicity, religion, national origin, gender, and economic status D A and B 10 Taboos and beliefs are: A Truths held by some cultures to be actual or true, based on specific rationale B Beliefs that are morally wrong C Taboos that describe what one should not D Beliefs about what is right and taboos about what is wrong REFERENCES Anderson, Y (1990) Health care across cultures, Nursing Outlook, 38(3), 136–139 Andrews, M (1998) Transcultural perspectives in nursing administration Journal of Nursing Administration, 28(11), 30–38 Bartol, G., & Richardson, L (1998) Using literature to create cultural competence Image, 301(1), 75–79 Benner, P., & Wrubel, I (1989) The primacy of caring: Stress and caring in health and illness Menlo Park, CA: AddisonWesley Betancourt, J., Green, A., & Carrillo, J (2002) Cultural competence in health care: Emerging frameworks and practical approaches (Field Report Publication No 576) New York: The Commonwealth Fund Blank, R., & Slipp, S (1994) Voices of diversity: Real people talk about problems and solutions in a workplace where everyone is not alike New York: AMACON (American Management Association) Byrd, R (1988) Positive therapeutic effects of intercessory prayer in coronary care unit population Southern Medical Journal, 81(7), 826–829 Campinha-Bacote, J (1999) A model and instrument for addressing cultural competence in health care Journal of Nursing Education, 38(5), 203–207 Campinha-Bacote, J.(1994) Cultural competence in psychiatric nursing: A conceptual model Nursing Clinics of North America, 29(1), 1–8 Coeling, H., & Simms, L (1993) Facilitating innovation at the nursing unit level through cultural assessment, part 1: How to keep management ideas from falling on deaf ears Journal of Nursing Administration, 23(4), 46–53 Dochterman, Y., & Kennedy-Grace, H (2001) Current issues in nursing (6th ed.) 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Upper Saddle River, NJ: Prentice Hall Health ... following skills and attributes EXCEPT: A Uses nursing concepts, principles, and available research findings to assess and guide practices B Understands and values the cultural beliefs and practices... colleagues, which facilitates learning about their ethnic and cultural heritages and assists in building trust and confidence in the leadership and management of the unit Planning workshops in cultural... decision making, and preferred leadership/ management style Nurses need to ensure that effective communication by staff with clients and others does not lead to misunderstandings and eventual alienation