Fostering nursing students’ cultural sensitivity to diverse community health clients
Objective: To analyze changes in nursing students’ sensitivity to diverse community health clients. Methods: Senior nursing students in a Community Health Nursing course were required to complete a reflective journal, self-performance evaluation, community agency evaluation, and essay questions on exams. These documents were read and pertinent information was abstracted for this article. The study covered the past seven semesters (September 1999 through December 2002). Results: Documents from 403 students were analyzed. Results revealed changes in sensitivity towards clients of diverse backgrounds. Conclusions: The personal contact with diverse community clients in community settings accomplished course objectives in sensitizing students. As students leave to practice as professional nurses, the potential impact of this sensitization may have profound effects.
KEY WORDS: Service Learning; Reflection; Nursing Students; Community Health Nursing.
File gumbo, Mardi Gras, and the calliope of the steamboat are national symbols of Louisiana and New Orleans. Everyone calls you “cher” and your “mawmaw makes groceries at the Schwegman’s”. The cultural heritage and history of New Orleans reads like a list of attractions at Jazzfest (Gospel, Caribbean, Jazz, Latin American, African, and Cajun). Near the mouth of the Mississippi river, New Orleans weathers hurricanes and floods and 100-degree temperatures in the summer. Day and night the French Quarter swings. The community’s health reflects its overindulgences in food, sex, and spirits. Laissez le bonne temps roule!1
Demographics of New Orleans (Orleans parish) illustrate its culture and values. The racial/ethnic heritage is reflected in its population statistics: 64% African-American, 34% Caucasian (includes French, Cajun, and American) (Louisiana Department of Health and Hospitals LDHH), 2002 p.38). The Hispanic (Caribbean, Latin and South America, Creole) and Asian (Vietnamese Boat people, Korean, Japanese, and Filipinos) aggregates (2%) were not described but comprise an influential effect on Orleans parish. Thirteen percent of the Orleans parish residents are 65 years and older, a growing proportion of the health needy aggregate (LDHH, 2002 p.39). Socioeconomic levels (per capita income-$22,642) reflect the range from corporate executives to self-employed fishermen (LDHH, 2002 p.39). Poverty still resides in the urban inner city with a report of 34% of the persons in Orleans parish and 52% of children under 18 years old live in poverty (LDHH, 2002 p.39). Major causes of mortality include cardiovascular and cerebrovascular diseases, cancer, diabetes, and homicide (LDHH, 2002 p. 62). Health and economic problems echo a joie de vivre2 (high life of entertainment and large quantities of rich food).
The Louisiana State University Health Sciences Center School of Nursing (SON) in New Orleans graduated 403 Baccalaureate nursing students (BSN), December 1999 through December 2002 (Table 1: Student demographics graduating in 12/99-12/02). Of these 403 graduates, 61% of the students were between 21-24 years old. A majority of the students accepted into the School of Nursing complete the program in the prescribed 6 semesters.
The student population does not reflect the demographics of the people served in Louisiana. This article will present actual clinical experiences designed to sensitize nursing students to their cultural, ethnic, racial, and age, values and perspectives of vulnerable populations served. Over the past several years, the curriculum has moved into community settings following the direction of primary health care. Two community health nursing courses provided the data for this article. BSN students have an introductory course in which community assessment of assets and needs are assembled. The second course intensifies knowledge and hands on experiences with vulnerable populations in their own environments.
Students are assigned to a selected community in the first course. In the senior course, three clinical days require work with/in each of these agencies in their community: elementary schools, a community resource, and home health agency. Relevant clinical experience objectives include: Incorporate into personal philosophy the value of providing service to her/his community, and communicate and plan interventions in a culturally competent manner. Nursing students working in pairs act autonomously to develop health promotion sessions/programs, communicate with clients, and accomplish rapport with clients and agency staff. Primarily the vulnerable groups affected are African-American, elementary school students to seniors, of both genders (personal communication from agencies’ materials and student documents). Although students focus on health care related activities; they often have other direct participation like serving congregate meals, playing games, conversation, and chaperoning field trips. These activities bring the student into one-on-one contact with minority clients in the clients’ environment. It is the belief the greatest change in sensitivity occurs for the student through this method. At the end of their clinical rotation, students organize portfolios of their accomplishments, which include a reflective journal, self-performance evaluation, and an agency evaluation.
Pre and post clinical conferences facilitate student cognizance and awareness of the impact of the clinical environment on their perceptions. These conferences are held at least once per week during the rotation. Small faculty to student ratios encourages analysis and vocalization of each student’s perceptions, reflection, and understanding. Faculty facilitates discussion through probing questions as well as assisting in appreciation of the causative factors to the client’s behavior. Sharing of clinical experiences broadens participating students’ knowledge of the cultural climate of the metropolitan New Orleans area. It is also felt that students find support in resonating feelings and understanding with their peers.
Collaborative community-based partnerships evolved between many agencies and the SON. Some partnerships have evolved and existed for years, while new ones are continuously forming. Students perform the community health nurse roles in health risk /physical assessments, health promotion education, and screenings (blood pressure, height, weight, insensate feet, tuberculosis). Table 2 provides a complete listing of agencies, vulnerable populations serviced, and students’ activities and impact. Coordinators and directors of these community resources document students’ performances at the completion of each rotation. In several of these agencies, faculty members contribute to the service learning by serving on the evaluation committees or boards, volunteer time, or assist with grant writing for agency support. Throughout the semester, students constructively critique themselves and their agency experiences.
For the past seven semesters, the authors have read and culled information from selected nursing student’s portfolios and post-conference discussions. Student comments were collected from self and agency evaluations, journals, and exam responses. One author describes the experiences from his perspective as a student with now 2 years of professional experience. The orientation of data collection was focused on cultural sensitization to vulnerable populations. (See: Table 2: Independent Community Based Experience Agencies utilized).
Results From Reflection
Reflection in the service-learning environment forms an integral part of the development of clinical and cultural competency. Bailey, Carpenter and Harrington’s (2002) study reinforced the proposition that “reflection positively affects student learning outcomes” (p.435). In SON’s community health nursing course, reflection is accomplished through pre- and post- conferences, student journaling and self (student) evaluations.
In clinical post-conference, a common theme expressed by students is ignorance of community resources and the challenge of linking exist resources to clients in need. Consistent with the participants in Zerwekh’s (2000) research, LSU nursing students work with gravely ill clients, drug abusers, indigents, and illegal aliens. Most clients are as Zerwekh proposes, “disenfranchised”, defined by their own fear and by the avoidance of others because they are “afraid of their behavior or afraid of encountering their intense level of hardship and suffering” (p. 51). Students are challenged with questions about “how would you handle….taking the children away from the mother, or deal with minimum social security check amount in this situation” or “Would that act be ethical?” or “Why do you think that client did that or made that choice?” In the evaluation of the agency, students respond to society’s responsibility to the particular vulnerable groups almost every student expresses empathy to the group and shows justification for society’s financial and emotional support.
Students learn quickly the limitations of community resources and subsequent consequences to clients. For example, one student assigned to the homeless shelter preformed tuberculosis testing. However, if the test was positive the student had to deal with loss of temporary housing and meals for that person as well as referral for evaluation. The student was perplexed that the client adjusted calmly to all these issues whereas she was distraught at the mere concept of sleeping “out on the street”. Uninsured Red Cross clients’ needs of prescription medications lost in a disaster presents a different response from students than elderly clients seeking free samples of medications. These two clients may have the same economic need and cultural prioritization of financial assets and personal needs. Searching for community resources broadens the student’s knowledge in what a client must do to get the service and the prospect that there are no resources available. As one student wrote in her course evaluation, “I did not know that these agencies existed within the City of New Orleans. I learned the importance of helping those, who are in need and providing referrals to others in order to get help for them and their families.” Zerwekh (2000) in her qualitative study discusses how challenges faced by community nurses often result in personal growth (p. 52-3). Specifically one of Zerwekh’s subjects describes helping those “on the ragged edge” as a “fight that kept [her] going.” (p. 52) Another research subject saw himself becoming “a better human being” (p. 53) as a result of facing his own prejudices against HIV patients.
Like the nurses in Zerwekh study, the nursing students grow personally from their challenges. Such personal growth includes a better appreciation of different cultures, as evidenced by the student’s verbal comments in clinical conferences and their written evaluations of their experiences. One student, whose experience took place in a senior center, reflected in a journaling entry,
I think working with seniors has got all of us thinking about the future of our own parents. Currently, I am going through a horrendous situation with my grandparents in Florida. They are still living on their own, but neither drives. Ninety percent of their friends are deceased and all other relatives are in California. It is scary to think how they manage their day-to-day activities. Thank God they have enough money to afford private transportation and help. But what about those without the resources. (Ron Stein’s journal)
As noted above, one third of the community clinical component is spent visiting clients in their homes. Client diagnoses vary, ranging from diabetes to terminal cancer. Culturally sensitive health promotion and treatment becomes a goal towards which students are encouraged to develop. As proposed by Heineken and McCoy (2000), students are encouraged “to quickly establish a close knit cooperative bond with all clients and their families, including those from cultures different from their own” (p.45). One situation involved a young, middle class Caucasian female nursing student who was assigned to the home of an elderly, indigent, African-American female with heart disease. The student was confronted with teaching the client future nutritional habits. Unbeknownst to the student saturated fats and other inexpensive staples of “soul food” were prevalent in the diets of New Orleans’ African Americans. The student made the following comments after her rotation, “I was able to see the differences between the views of most African Americans and myself when I tried to teach on healthy eating most of them would say I can’t afford to eat like that. I had to understand that this culture has low socioeconomic status and different eating habits.” Ultimately, in the above case, and after gaining trust of the client, the student was able to ascertain what foods the client liked and could afford, and guided her teaching accordingly.
Results From Self Evaluations
Contrary to previous semesters, students wrote their own clinical evaluations by responding to self-evaluation competencies. One competency is: The student demonstrates an understanding of cultural and worldview differences between and among individuals, communities, and the nurse. The following are exemplary statements:
In my home health rotation, I had to become aware of my client’s age in relation to historical things that may have shaped his life. I also had to look at the values of the older age group and what they cared about. I know that the differences between people keep things interesting and makes the world what it is. The student (me) has learned to be aware of other cultures when interacting with them. I must mold my care and approach to create a respect and rapport with my clients. (African-American female mid-twenties)
I was able to understand the cultural and world view differences between my community and my three clinical communities. Corpus Christi is a “Creole” community with a variety of individuals. NOCCA [New Orleans Center for Creative Arts] was a different type of school atmosphere than I had ever been in. The students were gifted in the arts and of a slightly younger but different generation than myself. I was able to see individual cultural differences at each of my patient’s homes. (Caucasian male early twenties)
Working with another student of a different race & background allowed me to view the same situations in a different view. Also visiting home health patients made me more aware of different cultures & religions & races can coexist in the same community. (Caucasian female mid-twenties)
My patients are different even though they are both Caucasian like myself. They have different lives & priorities. 1 don’t do the same things with both of them. I teach them different things & we talk about different things. They each have their own routine & time schedule & I respect that. They had different lives than the rest of the world due to their illness limitations. They can’t do everything that I can even though I wish they could. They live in very different atmospheres (1 private home, 1 nsg home). (Caucasian female early twenties)
A second question asked how students designed interventions that are considered culturally competent for the individual, family, or community. Responses included the following:
…By just speaking a few words of Spanish with [the client], she seemingly became more receptive and more willing to interact with the nursing students. I had to look up some of the Spanish I used. It was a little rough, but every week following the first time I spoke with her she came and to talked to me first. (Caucasian male mid-twenties)
…I was aware that their culture [Vietnamese] will not volunteer information about pain or discomfort. I was always sure to assess Mr. Tran’s facial expression for symptoms of discomfort. I also made sure that I called one of his children who spoke English to confirm that it was ok for me to come over and let them know when I was on my way. I also provided the son with a card to put on the wall with English phrases that Mr. or Mrs. Tran could use when an emergency arose. (African-American female late thirties)
A group of students in a parochial school used critical thinking in planning their health promotion bulletin board. These students portrayed the children in racial backgrounds of the aggregate (African-American, one or two Asian, and one or two Caucasian). In the newsletter for parents and children, the students used ethnic recipes. The interpretations by the BSN students were that there would be a greater level of acceptance of the health statements using these techniques.
Cultural interventions I used was to ask people in the same age range how they felt about things. Also, I had to research a little about the culture I cared for. I didn’t know anything about the Depression but know I have an Idea. I also talked to my client to see what cultural things they valued. I truly made time to ask about pictures to get info on how my client lived and who they were as people. I also looked at how my own culture affected my view of other cultures through values clarification. (African-American female mid-twenties)
Afore selected comments were considered outcome evidence of cultural sensitivity elicited in participating students. A qualitative analysis of all accessible materials would further support the authors’ hypothesis that clinical community experiences foster cultural sensitivity in nursing students.
Results From Essay Questions
How do faculty guarantee a transition of a sensitivity to future action? Generally and disappointingly senior LSUHSC BSN students approach the second community health nursing course verbalizing their impression that it is irrelevant and redundant to their career and licensure exam.4 Essay questions were placed on exams to encourage students to relate course theory (classroom activities/information) to clinical experience or relate community experiences/learning to their future practice. Essay questions utilized were:
* In discharge planning from an acute care unit, make a referral to an ICBE [Independent Community Based Experience] agency
* Propose a BSN activity related to your ICBE experience for the following roles of a CHN: Advocate, Researcher, and Collaborator
* Describe an issue related to the ICBE presentations that should go to the Louisiana Legislature for action
* Describe three clinical experiences from this semester that fulfill the definition of service learning.
Student responses recorded cultural and value sensitivity to the vulnerable groups affected in the ICBE experience. Examples were:
BSN students are researchers when they explore the percentage of the population in New Orleans, who smoke (including parents of these elementary school children). We must also research proven effective methods for educating young children about smoking. We have to research past effectiveness of Kick Butts Day in New Orleans and other communities.
The condition and resources for poverty-stricken individuals is terrible. The community centers are sometimes in poor condition. Many health centers (ie Central City) are inefficient and in terrible condition. One recent hot topic is the issue of obtaining the Hornets (professional basketball team). I am so angry that Louisiana is willing to give them a million dollar tax cut! I doubt it very seriously if they have ever experienced being poor in New Orleans. If they did, they’ll change their minds and tax the Hornets and give the money to health centers and such!
The Delta AIDS clinic in Uptown New Orleans should look to the Louisiana Legislature for increased funding to open another clinic in support of the HIV+/AIDS population. This disease is here to stay for a while and the legislatures need to realize that by opening several clinics to promote education and treat individuals is important for this state’s health and future citizens.
I would like to present to the Louisiana Legislature that we need funding for people who have C.P. [Cerebral Palsy] in order for them to be able to be accessible into all places. I think all restaurants, hotels, places of business need handicapped accessibility. Sidewalks need the curbs cut away to accommodate these people who are wheelchair bound. There are some sidewalks where a person in a wheelchair has to go into the street (next to the curb) for a bus. The buses are accessible but not all of the curbs so I would push for this to happen for these most important and deserving population! We are making progress in this area but there is still a lot we can do! We need to still have our voices heard!
Additional student comments which lead to the hypothesis that they will practice culturally competent care in the future included “developed effective communication skills with mentally challenged”, “…learned about the importance of listening to the patient and letting them explain to me what their concern is. Don’t assume what they need, just listen first.”, “Learning how to listen and read body language since you do not speak the same language. Have an understanding of the culture, eating habits, and how to incorporate that with needed healthcare.”, “Journaling also helped us to reflect on issues such as poverty as well as on our teaching effectiveness.”, “I learned about the clients. I had to be able to be very flexible in working with clients in their own homes. Sometimes I would show up with intended educational items, but find out that the client has other concerns that they would like to discuss.” These comments validate the impact of student experiences on future practice.
Limitations of this study may reduce the reliability of the outcome. A convenience sample of LSUHSC students’ written work was utilized. A qualitative analysis of the responses was not completed due to the plethora of community services and vulnerable groups, making responses/outcomes limited to any particular situation. Hawthorne effect5 strongly influences the students’ remarks, as completion of written work is a requirement to pass the course and to graduation.
Hands on participation in one on one contact with a member or groups of vulnerable populations can make life long changes to future nurses’ practice. Faculty members can role model culturally competent care and require readings about it, however changing behavior requires more intimate reactions through service learning experiences and reflection to establish implementation into the student’s practice. These students achieved more than a grade, more than knowledge, more than clinical experiences with these community interactions as reflected in their written work. The hope is that they reflect often on their practice performance to continue the process toward
1 Translated: Let the good times roll.
2 Translated: Joy of living.
3 Names of students authoring these responses have been withheld for privacy purposes; however, their age, sex, and racial background have been included to provide a better understanding of such comments.
4 Students have the impression that the licensure exam does not have community health content.
5 Currently the clinical experiences are graded in a pass/fail manner, however, the six previous classes were graded on a 7-point A-F scale, some classes had a contract for a grade, feelings were not graded only the completion of the activity (ie journaling).
Bailey, PA., Carpenter, DR., & Harrington, P. (2002). Theoretical foundations of service leaning in nursing education. Journal of Nursing Education 41,(10), 433-436.
Heineken, J. and McCoy, N. (2000). Establishing a bond with clients of different cultures. Home Healthcare Nurse. 18,(1), 45-51.
Louisiana Department of Health and Hospitals. (2002) Parish Profile of Orleans Parish. Online available at http://oph.dhh.state.la.us/PHP/getprofile5587.html?titleOrleans&pathreg1 Orleans
Zerwekh, JV. (2000). Caring on the ragged edge: nursing persons who are disenfranchised. Advances in Nursing Science. 22(4), 47-61
Ann Byerly, MPH, GNP-C, RN
Ron Stein, MHA, JD, RN
Ann Byerly, MPH, GNP-C, RN, Assistant Professor; Ron Stein, MHA, JD, RN, Staff Nurse and Attorney; School of Nursing, Louisiana State University Health Science Center, New Orleans, Louisiana.
Copyright Riley Publications, Inc. Center for the Study of Multiculturalism and Health Winter 2003
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