Meet two nurse educators who are teaching the next generation of nurses about cultural awareness. Hear what Margarita Trevino, a clinical assistant professor at the University of Texas at Arlington College of Nursing and the director of the Center for Hispanic Studies in Nursing and Health, and Julie Mattingly, an assistant professor of transcultural nursing at Methodist College in Peoria, Illinois have to say.
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Jamie Davis: Julie, Margarita, I want to welcome you to Nursing Notes Live and thank you very much for taking some time out of your busy schedules this summer and coming on the show to talk about what we’re going to be discussing today, which is cultural competency in nursing. Before we get started with that, though, I’d like to ask each of you, and I’ll start with Julie, tell us a little bit about why you wanted to become a nurse and how your education and career progressed that brought you to where you are today?
Julie Mattingly: Okay. Well, first, thanks for having me on the program. I’ve been a nurse for 22 years and I always knew that I wanted to do something in the healthcare field, but it wasn’t until I was a junior in high school and had the opportunity to do a day with a college on a clinical floor. It was called “Nurse for a Day,” where I got to see the student nurses in action. What really helped push me into nursing is, I remembered this visibly, the student nurses were caring for a patient who was a postman, a mailman who walked to deliver mail, and he had been trimming a tree and fell out of the tree and broke both of his legs. I remember going into his room with the student nurses and him telling me about his daughters that were nurses and how fantastic the profession was and how pleased that they were with their decision to become nurses. That for me pushed me into nursing as opposed to something else in the healthcare field. I am originally from Louisville, Kentucky and finished my Bachelor’s degree in South Carolina. My husband is retired from the Navy and I moved around a lot during my beginning career as a nurse, moved about every two or three years. My very first nursing job was on the island of Guam and then in Northern California and then in the Northeast. For me, I originally started out in the acute care setting, but after I had a child, I found that I needed something with a little bit more flexibility and went into Community Health Nursing and really found my passion there and have become interested in underserved populations and community wellness and health promotion. I have been teaching in a Bachelor’s program for about five years now.
Jamie: Fantastic. It sounds like you had quite a broad range of experience there with moving around and going to different facilities and things, but really finally found your passion after trying out something a little different.
Julie: Absolutely. That’s one of the things that I try to tell students is don’t give up on the profession. If you find yourself in a position after graduating from school, and maybe it’s not what you wanted to be, that there are so many options in nursing that you just need to continue to look because there is something for you. You were drawn to nursing for a reason and you just have to find your niche and sometimes it does take a little bit of time.
Jamie: Great. Margarita, how about you? Why did you want to become a nurse and how did you get to where you are today?
Margarita Treviño: Well, I grew up in a small southwest Texas community which was a minority community mostly populated by Mexican-American families. My parents were my role models in terms of being helpers. People would come to our home because they were both fluent bilingual for assistance in different ways. One of the local physicians trained my mother to give injections and so being there with a person in the community who needed long-term therapy, my mother would be the person that would give the injections for a week at a time. And I began to notice it wasn’t just in the health area but different social issues and work and so on. That community was not far from the border, Mexican border, so there were strangers in my home oftentimes. People who we hadn’t seen before probably wouldn’t see again but they kept come in to the doorway for food and help and so on. So being a “helper” was very normal for me. Going out of your comfort zone and reaching out to others. When I was in high school, I remember being ambivalent about should I be an educator because it’s just been a strong interest of mine to educate and the other was nursing. I thought if I become an educator I won’t be able to help people who are in need as far as health issues, but if I become a nurse, I will be able to do both. I can be a nurse educator and I can also practice in terms of clinical challenges. So I chose to become a nurse in order to be able to do both things. After graduation, I worked in the critical care unit in Houston where I had done most of my clinical preparation as an undergraduate student. Been relocated to North Texas where my husband was teaching in a university and I looked at public health for some of the regions that Julie also indicated. My family demands and my schedule at work were not compatible. As I looked at community health and having come from a community-based home, if you will, it was very attractive to me to get back into the environment where I would visit families in their homes, into their natural habitat, if you will, and go from there. So I wanted to also develop skills so that I could move into education. So I did some tours in public health in the Dallas-Fort Worth area in pediatrics, and I came from a strong Med-Surg background. I began to put those experiences together and then I moved into education. I’ve been on faculty at Baylor University College of Nursing and I progressed to Dallas Baptist University College of Nursing and other colleges in the social sciences area. I continued to build on a broad base in terms of education. In the interim, I have held positions in administration, different positions with health promotion, in particular. So I narrowed down my interests to health promotion and community health or public health. I earned Master’s with specialization in public health and also minored in Gerontology and Education. As my career progressed in different locations with a focus on community health and health promotion then I went ahead and earned a PhD with Administration Policy and Planning in Urban Affairs all of that to solidify my interest in community-based kinds of perspective with implications for nursing and implication for education. Ultimately, I had married those two interests academically with a doctorate in both areas and continue to pursue my interest in higher education. So the bulk of my practice has been for several direct patient care clinical practice kinds of things and ultimately education.
Jamie: And it seems like I have the right people to chat with here, two educators, because we’re really talking about something that has to be taught to a lot of nurses at the very beginning of their education to become a nurse. Because it’s so integral to the nursing process to help understand that patient in every aspect of their lives and that includes their cultural background. One of the things that I noticed when I was doing some research on this was that instead of cultural awareness, the words “cultural competency” kept coming up. I wonder, Margarita, if you’d like to jump in and just, first off, tell me what’s the difference between cultural awareness and cultural competency is. I really liked that term “competency”.
Margarita: Well, to me, it’s about application of better awareness. You have to have an awareness before you become competent is the way I would look at it. And awareness, to me, cultural awareness in my mind, puts the observer on the sideline. You can be aware of a lot of things and not do anything with it. But when you become competent, you have actually activated that awareness and have applied that awareness. To me, that’s the main difference. It is the difference between being a sideline observer and being a door.
Jamie: Julie, do you have any thoughts?
Julie: I think that’s a great description of the difference and would agree wholeheartedly with that description. I think the other thing to point out is, which wasn’t necessarily part of your question, but just that cultural competence while nursing students learn about it in school, it’s really not something that they ever reach. You’re never going to get to the point where you can say, “I’m culturally competent now.” It is always a work in progress. Even when a student finishes school and becomes a registered nurse, they’re going to need to keep working on their cultural competence. That it’s really a journey rather than a destination.
Jamie: I like that.
Margarita: I really like that additional thought from Julie because it is a lifelong learning process, and many times, you might get certified in cultural competency, but that doesn’t mean that there isn’t more to learn. So I support that decision of making it a lifelong learning process.
Jamie: Julie, what is it that makes nurses uniquely set up to reach this aspiration to be continually working towards cultural competency? Nurses, as opposed to other healthcare professionals, have a different approach to the patient and I’m curious what your thoughts are about what it is that makes nurses such an important part of this process.
Julie: So I think as the front line within the healthcare field, that it’s oftentimes the nurse who is going to have sometimes those difficult discussions or interactions about specific things related to health. As a nurse, we learn how to use the process, to assess patients, and we need to look at the patient as a whole not just their single health problem or their multiple health problems. We need to look at their family, where they come from in the community, their spirituality, their mental health. To be able to provide the very best care that we can, we need to understand the patient’s view point. We are now, as the healthcare across-the-board, not just for nursing, but we’re seeking better outcomes for our patients. If we don’t understand our patient’s cultural viewpoint and how their health beliefs impact what they do in relation to their health, for example, then we’re never going to help them on their journey to wellness, whatever that wellness may be, whether it’s an absence of disease or just the control of symptoms.
Jamie: I’m curious, Margarita, what do you think are some of the most challenging aspects of integrating cultural competency into nursing care?
Margarita: I think we need to begin as early on as we can with our students, for example, in developing a sense of self-awareness of our own personal values, personal belief system, and how this would ultimately translate into providing care for individual families and the community. Sometimes we don’t want to deal with that. We’re too busy with the demands of academics, and heavy schedule and so on that the personhood of that nurse is sort of put on the sidelines or aside. One of the things that I noticed when we asked those kinds of questions to our students is, “Well, I don’t agree with my patient’s beliefs or practices, but then I really don’t have to. I can park myself on the outside and walking to a room and just do what needs to be done.” To me, that’s not holistic care. We cannot separate ourselves from those whose lives we touch. I would say, get to know yourself, be comfortable with yourself, identify the strengths that you have as a person because we can’t wear two hats – the person hat and the nurse hat. We’re two-in-one. Celebrate who you are. Identify areas that you might need to work on. For example, sometimes I’ve heard testimonies from nurses who will say, “Well, I don’t like to give care to anyone who doesn’t speak English.” Well, not everyone’s going to speak English. What are you going to do to accommodate to that reality? Again, because that opens the door to frustration and, rightfully so, because it’s a communication barrier. So what should the nurse do? Don’t allow that variance in expectations, just like the patient who may wish the nurse would speak into her language. Don’t allow those kinds of variances keep you from pushing beyond that limitation and connecting with the patient. But I’d love to pivot one the sense of self of the nurse into one of the keys that will open the door to a lot of the things we see and hear in cultural variances between provider and patients. If we’re comfortable with who we are, we will be successful and honest with who we are. Identifying strengths and identifying limitations, then doing something about that, should not keep us from connecting effectively with our patient population or client population and the family and the community. I love to celebrate personhood and sometimes it’s really easy in today’s reality to put ourselves on the outside and take care of all the other things that are in front of it. But if we keep a person’s awareness of ourselves then celebrate who we are and reach out because of who we are, I think we’ll have healthy relationships with our patients in time, regardless of their cultural differences.
Julie: And if I can chime in on that note as well, I agree again with Margarita that even before we can, as nurses, assess a patient or a family or a community and their cultural preferences, we need to assess ourselves. With teaching transcultural nursing, that’s one of the things that I think the students sometimes struggle with initially is, it’s one of their very first assignments in the lecture course on transcultural nursing that I teach, is I ask the students to describe their own culture and to give some analysis to who they are as a person. And sometimes what I’m told when I give that assignment is, “Well, I don’t have a culture.” Well, no, you do. You need to dig a little bit deeper and you need to understand that culture is not about race and ethnicity, although that does play a part, it is about values and beliefs as Margarita mentioned and that we need to kind of dig deep and know ourselves and perhaps know what kinds of patients may trigger negative feelings, whether it would be stereotypes or bias and kind of have a plan on how we can bridge that gap. Most of the time, we keep those kinds of feelings really under the surface like an iceberg, and they don’t come out, but yet they stew inside us and cause kind of turmoil for us and that makes those interactions more difficult to really give that culturally competent care and to really be genuine in your interaction.
Margarita: Julia, I really like your idea of having a plan, which gets back to understanding of – because, let’s say a nurse walks into a room knowing that the patient is not conversant and, let’s say, in English, for example. If that’s going to cause frustration because of the lack of communication skills on either side, the nurse already knows that. The thing that sometimes we don’t pay attention to is that that frustration, whether it’s verbalized or not, and chances are the nurse doesn’t verbalize the frustration, is that you don’t have to verbalize. The patient will pick up on it. If a nurse walks into a room with hesitancy, with preoccupation, it’s going to be all over his or her face and the patient can sense the tension, if you will. So having a plan, I think it is critical that the question is what should that plan look like. It seems to me that one of the things that would be sort of anticipatory guidance would be, know that there is a language barrier when you go in there and do everything you can to put that patient at ease through interpreters, through – “Go ahead and speak English” – I’m thinking Spanish-English, we’re not talking about biculturalism in this case, which has been the bulk of my experience. Don’t assume that the patient doesn’t understand any English or there might be someone in the room, a family member, who can translate for you. But put the family at ease. Put the patient at ease. And you would anticipate that as times goes on, if the patient is hospitalized where they are too or whether it’s a community health clinic or whatever the setting, that you want to build on trust. You want to build on the confidence factor between the two of you and, in most cases, nurses report that when they take advantage of those kinds of situations instead of viewing them as a barrier, that they become more able to give good patient care and the patient needs to be respected and you end up with a win-win situation.
Jamie: I like that and both your statements bring me back to something an instructor said when I was in nursing school that talked about dealing with – before you can deal with any patient, whatever their cultural background, you need to really have a good handle on your own blind spots. That’s what she always used to say, was calling our “blind spots” and we have them in our ethics, in our morals and in our cultural backgrounds that creep up and can hide from us. And I like the idea, Julie, of having students write down and define their own culture first because it really helps me to expose some of those blind spots.
Julie: Yes. I think it’s always valuable to me in getting to know the students, but as students write, it can be very – you can almost see them becoming more enlightened as they complete the assignment and they’ll start off with, “Well, I live in a small town where there is very little diversity,” and then they really pick up and get going with what’s valuable to them and they start to see where maybe they haven’t had a lot of interactions with different cultures and I think it’s just a great place to start.
Jamie: So what is it that a nurse can do, Julie, to improve their cultural competency? You talked about it as being this ongoing process and something that we all need to work towards improving constantly. But what is it that a nurse can do on a regular basis to keep this thought process of being culturally competent? We’re working towards cultural competency out in front of them.
Julie: Well, I think that it has to be part, not to say that it becomes routine, I don’t want to imply that, but there needs to be some kind of cultural assessment completed for every patient. I think that we’re starting to see that more and more in the acute setting when the nurse does an admission assessment. But even just some simple questions about – “Is there anything that you’d like to share with me about your culture that would help me to provide you better care?” Or even into more specific questions about diet and family and family roles. But also for the nurse to realize that even with answering these questions, that they may make a mistake in their interaction. They may touch a patient that prefers not to have personal touch or may refer to the patient by their first name when they would’ve preferred to be called “Mr.” whatever their last name is. If mistakes do happen, that they acknowledge those mistakes, that they can apologize to the patient if necessary and say, “I apologize. I didn’t realize that you prefer not to be touched. Is there anything else you can tell me?” and just use every interaction as a potential learning experience. And if there are some of the harder interactions that occur that end up being difficult for the nurse that they’re having difficulty in processing, that they utilize some kind of resource within their institution or their agency. Perhaps that’s a chaplain. Perhaps that’s somebody else, but there should be somebody that the nurse can utilize as a resource to discuss interactions and if they have had some difficulty. I think also any kind of ongoing training, that now is a joint commission standard, if my memory serves me, I’m not in the acute care setting, but just any kind of training to keep the need for cultural competence at the forefront. Also even for the area that you live in, become familiar with what is most common if it is about race and ethnicity. What are the most common races and ethnicities in the area? For the area that the school that I work at is in, it’s predominantly African-American. Also we are beginning to see an influx of Asian-Indians, because of a large corporation that’s here and also a larger university. So with those cultures are their specific beliefs. But with that being said, we also have to be careful and not make assumptions that every person from this race or ethnicity has the same cultural beliefs. So again that’s where that individual cultural assessment comes into play.
Jamie: Margarita, what are your thoughts about what a nurse can do in an ongoing process to improve their cultural competency?
Margarita: Well, I would echo what Julie said, and one of things that I would reiterate is looking for resources to equip him or herself as a nurse to be able to bridge those gaps, whatever they may be. And they will vary depending on the setting. Whether it’s the rural area or whether it’s a metropolitan area, whether it is a public health setting, an acute care setting and depending on the age continuum as well of the patient. Again, I want to also reiterate that it is a lifelong learning process and just not assuming again the point that Julie made that once you get to know a particular cultural or racial group, that everybody’s going to be the same. With Hispanic, for example, we have a lot of subgroups and there are a lot of unique characteristics of every subgroup. For example, one word that may be acceptable in the language used by most Puerto Ricans may not be acceptable by the Cubans, may not be acceptable by Mexican-Americans and so on. So talking about the state and one of the things that is – while there are some commonalities across the cultures, for example, with Hispanic in a large majority, giving a person direct eye contact is a no-no because it’s a sign of aggression. If I was the nurse at the bedside of a Hispanic patient and I’m talking to the patient, I would not necessarily expect the patient to look me directly in the eye. Does that mean they’re not paying attention, they’re not understanding, they might be somewhere else? No. It’s a cultural trait. It’s a cultural predisposition. They grew up not giving direct eye contact. For example, that’s a norm that we could probably transfer to the majority of Hispanic-origin cultures. But then there are very important differences as well. Even within Hispanics, some tend to embrace and it’s very natural to embrace woman to woman, man to man, adults to children and vice-versa. In some families, you don’t embrace. Period. You don’t embrace. It’s not a cultural characteristic of that family system and so you don’t cross that line. That’s why again the uniqueness, the variances that you find among families and individuals is critical to – “How will I as a nurse be able to identify points of connectivity between who I am and whom I’m serving, whom I’m trying to serve as my patient, family and the community?” From a cultural perspective, it is also important, Jamie, to remember, and Julie, that in most cases where we have Hispanic patients or clients – I’m using the word “clients” to connote a healthy person who’s receiving healthcare services versus a patient – it is important to keep the family in mind because we can – and I say “we” because I’m Hispanic – we tend to aggregate when it comes to times of crises or times of needs So we can’t just focus on the patient or the client, we have to think my dad’s kids, grandkids, the whatever, and be in the community at large to the degree that we can. In other words, we can’t just disconnect. Once you take care of the patient or client, then you disconnect, you don’t have to be concerned about the rest of that family system. But in being an effective change agent as a nurse, in being effective in meeting the healthcare goals and outcomes, we have to think more in terms of inclusivity, in terms of who will be impacted by the decisions that you as a nurse make in relation to taking care of that person.
Julie: I think those are excellent examples and from my experiences with traveling to the Pine Ridge Reservation in South Dakota, one of the cultural differences that, for me, I don’t necessarily struggle with it anymore, but certainly when I began my visits was a challenge, and that was the use of silence during communication. I think that with using silence in my culture during a conversation – if I am talking to someone and we’re conversing and suddenly the other person is silent for even a minute or two, I would think that something was wrong. I would want to prompt them. I would ask them if they were okay. Within the Lakota Sioux culture, the use of silence is used to show respect to the person who is talking. It’s an opportunity to kind of let the conversation sink in and it’s a time of reflection. If you didn’t know that that was going to happen, that can really cause some issues within the interaction. I think that’s one of the difficulties that, in our current state of healthcare, if we were to have a patient of that culture here in my town in Illinois and they went to the doctor for some kind of visit and that amount of time was blocked off, 20 minutes, for the primary care provider to come in and have that visit with the patient. The patient then uses silence during the interaction. It could potentially extend the visit longer than 20 minutes. This is also a culture that uses a lot of oral storytelling and that’s just part of, before we can get to the point of talking about health or any current symptoms or current difficulties, there’s usually going to be a story before that part of the discussion comes out. So our 20-minute healthcare visit is not really going to meet the needs of the patient. If they need much longer, the interaction – for them to have a meaningful interaction, they’re going to use their silence and their storytelling and – “Well, that’s not part of my culture. It’s part of theirs.” And if we’re going to have that cultural competence, don’t we need to then allow these communication styles to come into play? I think that’s also one of the things that we just get into trouble with, that we expect everybody to follow what we consider normal, that ethnocentrism, where we think that our culture is the only way. I don’t think in healthcare we’re necessarily always built to allow the personal differences that need to come into play.
Make sure you check out the entire August, 2014 issue of Nursing Notes, where we look at cultural competency in nursing. You can read the entire issue online at www.discovernursing.com and don’t miss the other Nursing Notes Live episode this month where I sit down with our Get to Know Nurse Regina Wysocki, a school nurse and an alumna of the Johnson & Johnson School Health Leadership Program. You’ll find this and other episodes of Nursing Notes Live in the podcast area on iTunes.