Lessons learned: providing culturally competent care in a nurse-managed center
Abstract: The author discusses the conceptualization and implementation of a university and community sponsored nursing care center to meet the needs of the community. A case study is given illustrating the cogent points dealt with in the article.
Key Words: Nurse-Managed Center, Culturally Competent Nursing Care
The University of Central Florida (UCF) is located in Orlando, Florida and has branch campuses in Volusia and Brevard counties. The mission of the university is to provide excellent accessible education that serves the needs of area residents. In fulfilling this mission, the University believes it should participate in and contribute to the community.
On each of the campuses, the university offers a baccalaureate degree program in nursing. As part of the program, students have a public/community health course. Public Health Nursing has a long history of advocating for needs of poor, disenfranchised people. The UCF Nursing Department has a strong commitment to providing community health education experiences for their students that are responsive to rapid changes and inadequacies of the existing health care system. The UCF’s Community Nursing Center, a nurse-managed center, was created to meet the needs of the community it serves, and has been in operation since April, 1992.
The mission of the University of Central Florida’s Community Nursing Center, Project Liftoff, is to involve student nurses in the educational process of fostering individual and community participation in solving health problems and issues affecting clients they serve. The conceptual framework for Project Liftoff is one of individual and community empowerment; processes involve information, skills, and resources to improve decision-making power of individuals and groups served by the project.
The UCF Community Nursing Center has partners that have contributed greatly to the project and its existence. Current partners include Brevard County Public Health Unity, Brevard County Housing Authority (Housing and Urban Development [HUD]), United Way, Brevard County Family Services, Prenatal and Infant Health Care Coalition of Brevard County, Inc., Community Commons (a coalition of banks, businesses, social service organizations and Brevard Community College), and UCF. Brevard County Housing Authority contributes a three-room unit with water, gas, and parking in the housing project for the Community Nursing Center. The United Way donates funds for two phone lines. Brevard County Family Services assumes expenses of the electric bill; and the Brevard County Public Health Department provides consultative and referral services for clients with complex health matters, especially as they relate to issues of pregnancy, reproduction, and child health. The Health Department supports the Community Nursing Center with supplies. They also support and endorse the notion of nursing students providing primary care directly in client’s homes.
At the UCF Community Nursing Center, nursing students are the pivotal providers who see community residents for planned care. Project Liftoff operates twelve months a year. Services provided by students are under the supervision of experienced faculty and through faculty practice. This faculty has a variety of experiences working in minority communities, often spearheading innovative culturally appropriate models of health care delivery. The faculty has a multicultural background, and all of its members have served on cultural diversity committees. Specialty experiences and education of nursing faculty are in women’s health, pediatric health, community health, and community organization.
CLIENT POPULATION SERVED
The population being served by Project Liftoff is the most heavily concentrated area of low income African Americans in Cocoa and Brevard Counties. There are 710 apartments, housing approximately 4,250 residents. Of those, 3,272 are African American. Sixty-three percent of the residents served by Project Liftoff have incomes below the poverty level, with an average household income of $10,940 per annum. Fifty-three percent of the population is of childbearing age (U.S. Census Data, 2000).
Infant mortality, an indirect measure of the health of the mother and infant, and the effectiveness of the health care system is 15/1000 for non-white infants compared to 7/1000 for white infants in Brevard County. Prenatal care begun in the first trimester of pregnancy, an important predictor of healthy babies, was at 77% in Brevard County as a whole, but at only 50% for the high-risk populations (Improved Pregnancy Outcome Data, 1993). Teen pregnancy was at 50.9/1000, ages 15-19 in 1991. For non-white teens, this figure is 116.3/1000. It is estimated that half of these mothers will become mothers for the second time within two years (Healthy Beginnings: University of South Florida, 1999). The project has positively impacted the number of low birth weight infants born in this zip code, decreasing the rate from 11.4 to 7.6 over the last six years (Prenatal & Infant Health Care Coalition of Brevard, 2001).
HIGH RISK PROJECT POPULATION
The profile of the target population can be characterized as isolated in the fullest sense of the word: economically, culturally, and psychologically; functionally illiterate, communicatively incapacitated, socially deficient, and inter-generationally impoverished. Health problems affecting the target population include: teen pregnancy, unwanted pregnancies, AIDS, lack of access or utilization of available health services, school dropouts, crime, substance abuse, unemployment, and low self-esteem. Intense family assessment done by UCF nursing students of the area reveal that these problems are extremely complex and root causes are frequently related to sociocultural barriers that prevent them from benefiting from existing resources in the area.
Removing sociocultural barriers between receivers and providers of care is an important emphasis of the Community Nursing Center. The following is an example of lessons learned in addressing the care of a young prenatal African-American client.
The large, African-American, pregnant, teen-age population seen at the Community Nursing Center poses a challenge for the staff of Project Liftoff. The following describes a clinical scenario involving a 14 year-old, African-American girl.
Cami is a middle school student who wears the current style baggy clothes. She resides with her stepfather, mother and four sisters in a three-bedroom apartment one block away from the clinic. Cami has visited the center on several occasions to participate in health fairs and teen classes. She has come to the center today with a friend and a greasy brown bag of French fries covered with ketchup complaining of nausea. We discuss her diet and how it may contribute to not feeling well. She requests a glass of milk, which usually relieves her discomfort and is given one. She weighs herself and leaves.
Cami comes in several days later by herself looking very upset. She is taken into a private area to talk and says she is pregnant. She is very worried about what her stepfather will do; on the other hand, her mother had her when she was thirteen years old–“so she cannot say too much.” A family disagreement erupts, because Cami will not reveal the identity of the baby’s father to her stepfather. A referral is made to the public health unit for the daughter and mother.
A visit to the public health unit reveals that Cami is five months pregnant and has gained three pounds. Her weight is of concern because she is 5 feet 4 inches, weighs ninety-six pounds and has a Body Mass Index (BMI) of 16.5, which showa that she is underweight. A referral is made to the Healthy Start Program at the Nursing Center, because she has several risk factors: race, age, weight, education, marital status and late entrance into prenatal care. The goal of this program is to reduce infant mortality and the number of low birth weight babies, as well as improve health and developmental outcomes.
One of the first concerns for this young, pregnant adolescent is her late entrance into prenatal care. Her risk factors were explained, and the importance of getting to her doctor’s appointments is emphasized, with an offer to provide transportation for visits when needed. For reasons that are unclear, African-Americans are twice as likely to have a preterm or low birth weight baby or experience an infant death (Healthy Start System, 2002)
Cami continues to attend school and is enrolled in a community-based childbirth program. This holistic program provides childbirth classes with an emphasis on parenting skills and self-development. Classes are held over ten weeks with participants grouped according to age and due date. Cami’s group has ten participants ranging in age from fourteen to seventeen years. Bonds of social support were often visible between participants. They would have celebrations for births, birthdays, and graduations. Participants looked out for each other encouraging good weight gain and healthy preparations for their soon to arrive babies.
Cami’s diet was often the focus of conversation, because of poor weight gain and poor eating habits. In approximately her sixth month of pregnancy, she began to look puffy and her hands and feet began to swell. She started keeping a diary of the foods and liquids she consumed, which showed it to be laced with chips, soda, and French fries. Diet counseling was started with her, and her mother examined some changes in Cami’s diet that would be beneficial that the whole family could eat. A menu was developed that had foods the family consumed such as dark green vegetables, meats, and starches. A week later, Cami still appeared puffy and swollen even though she had stayed on her new diet. She was very disappointed and did not see a need to stay on the diet plan. In talking about the diet, she revealed that many of the vegetables were prepared with ingredients high in sodium such as ham and butter. After discussing how diets should not contain these high sodium foods she asked, “So you want me to cook and eat like a white person?”
Cami’s statement regarding her diet caused us to re-examine how we went about teaching people how to diet. We also sought out to discover what foods were available in the local grocery stores, because there were no supermarkets within walking distance. This group developed a cookbook of healthy diet plans with the assistance of the staff at the center. Cami did begin to gain weight and look less puffy, and her blood pressure stayed within an acceptable range. Unfortunately, the ending of her pregnancy was not a happy one.
After one of the weekly visits to her doctor, Cami felt no movement from the baby. A visit to the emergency department showed that there was no heartbeat. This baby’s death devastated young Cami. She spoke in a low voice and said she couldn’t understand why her baby was taken. At her postpartum check-up she refused birth control stating she would not be having sex again. Her affect was still very flat eight weeks later, and counseling was advised. Her stepfather would not let her leave the house and was very suspicious of the clinic staff.
Counseling was refused, but she could speak to a minister. Fortunately, the young, black, female minister who worked with us was available to see her. After about two weeks a positive relationship developed between the two. Cami was killed two weeks later in a car accident. The impact on this family was great and a new set of issues had to be dealt with by the young minister.
SUMMARY AND CONCLUSION
Project Liftoff provides an opportunity for students and faculty to have learning experiences viewed through a cultural lens. Care is planned by using the community’s resources. Alternative strategies of care for the community may need to be examined, such as the counseling was unacceptable, but talking to the local minister was acceptable. The availability and norms of the community need to be taken into account when developing diets. To develop trust and acceptance within the community, an advisory board, consisting of community leaders, meets to discuss what is happening in the community and how the Community Nursing Center can have a positive impact on it and its residents. This on-going dialogue helps both the staff and the community to gain a greater understanding of the issues which effect the participation of the community members in health care maintenance activities.
Healthy Beginnings Conference Syllabus. December, 1999). University of South Florida, Orlando, Florida.
Prenatal & Infant Health Care Coalition of Brevard, Inc. (2001). Semi-annual report of 2002/2001. Brevard County, Florida.
Prenatal & Infant Health Care Coalition of Brevard, Inc. (1993). Improved pregnancy outcome data. Brevard County, Florida.
US Census Data (2002). From http://ferret.bls.census.gov
Valerie Browne-Krimsley, EdD, RN, is an associate professor and program director in the School of Nursing, University of Central Florida in Cocoa, Florida.
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