International Journal of Nursing Practice 2000; 6: 146152
INTRODUCTIONAny research project must have as a basis valid reasons forits instigation.The research should be useful in improvingcurrent practices in changing contexts, to introduce newconcepts or to evaluate the effectiveness of current prac-tices or, in fact, to validate the existence of current prac-tices.The research questions for this Masters of Educationmajor thesis, which were based on the premise that cul-turally and linguistically diverse (CLD) registered nurseshave culturally based nursing knowledge, skills and exper-tise, were as follows:1. What kinds of culturally based nursing knowledge,skills and expertise do CLD nurses possess?
2. What contribution or influence or change can thisinformation make to nursing education and practice inAustralia?
The significance of the study is clear: that is, the resultscould modify the way nurses are educated. Such modifi-cations involve discovering what changes need to be madeand how the cultural attributes that CLD nurses bring toAustralia can be utilized to improve nursing education andpractice for Australias multicultural population. Thewider implication of this study includes an understand-ing of what CLD patients may expect regarding nursingcare, and how changes in nursing education and practicethat take into consideration CLD nurses culturally basednursing knowledge, skills and expertise may overcomeperceived shortfalls in these expectations.
The target group for this research project was overseas-qualified registered nurses from non-English-speakingbackgrounds. All nurses who participated in migrantnurses pre-registration programs in Melbourne from
R E S E A R C H P A P E R
Recommendations for culturally sensitive nursing care
Patricia Josipovic RN; DipAppSc(NsgEd), BAppSc(Nsg), MEdCourse Coordinator, School of Nursing, Deakin University, Burwood,Victoria, Australia
Accepted for publication June 1999
Patricia Josipovic. International Journal of Nursing Practice 2000; 6: 146152Recommendations for culturally sensitive nursing care
Australias health care clientele reflects the diversity of this multicultural society. Patients and health care professionalshave expectations of health care which may not be met to their satisfaction or needs. The perceived inadequacies of andincreased demands on the Australian health care system are reflected in the literature and by active political lobbying.Thus, there is an urgent need to investigate how the health care system can be improved and how recommendations fromresearch can be put into place. One mechanism that may provide some of the changes required is to use the skills, ex-perience and qualifications of culturally and linguistically diverse nurses. This paper, which is based on a descriptive ethnographic research project, will provide insight for utilizing this valuable and available resource, and how nursing education curricula can be modified to adequately incorporate transcultural nursing practices, so that nurses can meetthe challenges of caring for Australias multicultural population.
Correspondence: Patricia Josipovic, 16 Canterbury Street, Yarraville,Victoria 3013, Australia. Fax: +61 3 9314 8483; Email:email@example.com
Culturally sensitive nursing care 147
1991 to 1993 were surveyed. The questionnaire wasdeveloped on themes explored in the literature review.
Themes involving nursing practice included:
Pain and nursing care Touch and nursing care Cleanliness/hygiene and nursing care Death and nursing care Communication skills and nursing care Nursing education policies Political influences
Five educational institutions were involved and 150questionnaires were sent out. Of these, 49 nurses re-sponded and from these, 16 agreed to be interviewed.Theinterview utilized trigger questions from the literatureand issues raised from responses to the questionnaire.Sample trigger questions are:
Could you describe the status of nursing in the countryyou practised, other than in Australia?
Can you tell me about some customs or traditions [ofcultures other than Australia] with regard to touch,cleanliness, diet, death and so on?
Are there any differences that you noticed in nursingpractice, education/training, role of the family etc.,between your country and Australia?The in-depth interviews and field notes were tran-
scribed.The findings from the questionnaire and interviewdata were analysed for emerging themes that linked thequestionnaire and interview data with the major cat-egories identified from the literature review. Discussion ofthis thematic analysis will now follow. Recommendationsmade in the discussion are a result of the data collectedfrom the study participants and the researchers ownknowledge and experience.
LANGUAGE ISSUESMajor inhibiting factors to effective nursing care and internal com-
munication within a profession is a lack of information and skills
in working cross culturally.1
The data collected revealed certain distinct suggestionsfrom the respondents, based on their own experiences,with regard to cultural topics that should be included innursing courses and practice in order to provide cultur-ally sensitive nursing care, including learning another language. Just as vital, the respondents believed, was the congruency of languages and ethnic background ofpatients and nurses, where possible, as there are a lot ofcultural issues inherent in language.
Respondents recommendations included:
the introduction of elective subjects such as LanguagesOther than English (LOTE) in nursing educational programs;
giving award exemptions or credits for nursing stu-dents who speak fluently a language other than English;
the employment of bilingual nurses in health care settings;
encouraging institutions to give financial remuneration,or promotional/seniority positions for fluency in lan-guages in addition to English;
the formation of a data bank of languages spoken bynurses and a rostering system that promotes optimaluse of these specialist nurses; and
developing a system of identification of nurses who arefluent in languages other than English, indicating lan-guages spoken for easier recognition by patients andother nurses.These recommendations could imply that, in some
instances, the services of qualified interpreters, which canbe a scarce commodity, could be utilized more effectivelyif bilingual nurses can share this workload.
CULTURAL UNDERSTANDINGImproving understanding of different cultures was anothersuggestion that arose from the data.The implication of thisfinding is that,with this knowledge,nurses will have a muchbetter understanding of patient behaviour and be able toimplement culturally appropriate nursing care. It is notsuggested that nurses should know everything there is toknow about each cultural group that they may come in con-tact with; this is impractical from a curriculum perspective,as well as an unnecessary knowledge overload. Rather, thefollowing recommendations should be implemented:
Cultural awareness and cultural sensitivity should betaught throughout nursing curricula.
Experiences should be shared between CLD nurses andother nurses in a formal and informal manner in theclassroom, such as with guest speakers or in profes-sional staff development sessions.
There needs to be official recognition of these nursingcultural skills, such as by outlining them as part of thespecific duties of a position.
CLD nurses experiences should be published. Australian nursing research projects should be insti-
gated to explore solutions to perceived problem areas,such as cultural differences in health and illness prac-tices, and the use of health care services.
148 P. Josipovic
This should be done to increase the pool of informa-tion, to change perceptions and to aid in the removal ofstereotypes and racial barriers. The recommendation for the instigation of research could also assist in develop-ing knowledge and subsequent theories and to validatefindings: this would be essential to promoting multicul-tural health care as a valid and credible field of study.According to the Royal College of Nursing Australia,research these days is becoming the backbone of many tertiary institutions, and increasingly so in the field ofnursing, both at the tertiary level and health care setting.2
Targeting issues that have bearing on a large proportion ofpatients would appear to be a very forward-looking strat-egy, which could be at the forefront of changing healthcare policies from a practice point of view. This recom-mendation could also put the nursing profession at theforefront of such an integral field of research.
Recent pioneering developments in nursing educationthat incorporate other health belief models, such as thosecited by Tan3 and Boyle and Andrews,4 have seen the intro-duction of complementary therapies in nursing prac-tice. One university in Victoria is now offering tertiary-based complementary therapy courses, which include aromatherapy, acupuncture and therapeutic massage. TheNurses Board of Victoria has also established guidelines forthe use of such therapies in nursing practice.This indicatesthat the Board generally accepts this new avenue of nursingpractice in recognition of the increasing interest shown in complementary or alternative therapies by the generalcommunityand by a significant number of nurses.5 Atthe time of writing this article, the author acknowledgesthat courses in complementary therapies are emerging inother health and nursing faculties across Australia.
Other nursing issues requiring cultural understandingthat have been identified in the literature and the data are:
gender, in relation to the acceptance of differentgenders in the nursepatient relationship;
family role and expectations in providing care; respect and how it is demonstrated between nurse and
patient, and nurse and other health-care professionals;
use of appropriate touch in providing nursing care andin the healing process;
sensation of pain and acceptable management; practices associated with cleanliness and hygiene; dietary considerations in the healing process; and rituals related to death and dying.
These are issues that are part of everyday nursing practice, and therefore have major implications for pro-
viding a high standard of nursing education and compe-tent practice.68
It is necessary to not underestimate the damage thatdisrespect of anothers culture can do to the therapeuticrelationship between the nurse and the patient.The wrongassumptions about appropriate behaviour can bring avariety of problems from both the patients and the nursesperspective, in almost the same way as a misunderstand-ing of a code of cultural manners.Again, these issues needto be stressed both at nursing curricular and professionalstaff development levels, and also for individual develop-ment of culturally appropriate interpersonal skills.
PRIOR LEARNING ANDCURRICULUM IMPLICATIONS
Prior learning and curriculum implications was a majortheme that resulted from the findings of the data and literature review9 and this theme influenced many otherissues.
An innovative educator can utilize many teaching/learning strategies to enhance skill and knowledge acqui-sition in this exciting and dynamic field. The recognitionof prior learning is important, especially in the under- and post-graduate sector of the nursing student popu-lation. Johnson suggests that an innovative [educational]approach enhances the past learning experiences of theculturally diverse adult learner.9 Culturally and linguisti-cally diverse nurses should have their prior learning rec-ognised by tertiary sectors. Prior learning is that learningnot obtained during the pre-registration program theycompleted in Australia, but the learning that they haveacquired overseas. This recognition is different to recog-nition of qualifications for practice.This prior learning canassist not only in claiming for credits in some courses, butact as a boost to self-esteem and self worth.
Recognition of prior learning also has implications for curriculum developments. Hofstede, who writesabout the differences in processes of teacherstudent,studentstudent interaction and cognitive abilities, hassuggested that teaching a student body who have a differ-ent cognitive profile than the teacher or other students isproblematic for the teacher, who may not have the properabilities or educational background: There is no othersolution to bridging this gap than increasing awareness,sustained effort on all sides, focusing on new abilitiesdemanded by societal changes of the moment andpatience.10 This will provide an avenue for fruitful cross-
Culturally sensitive nursing care 149
cultural learning between student(s) and teacher(s) and,by implication, between nurses and patients.
For organizations that offer subjects in multiculturalhealth/nursing care, another suggestion by the question-naire respondents was to increase the duration of thesesubjects, and for organizations that do not currently offerthese subjects to include them in curricula planning.DCruz and Tham have already discovered in theirresearch that, on the whole, most tertiary organizationsthat run nursing programs make a tokenistic reference to multicultural health care issues in their nursing cur-ricula.11 This nominal inclusion of multicultural healthcare practices in most nursing curricula does not reflectthe clientele for whom nurses in Australia are expected toprovide quality care. Personal experience in the super-vision of undergraduate student nurses has indicated thatthese nurses feel inadequately prepared to care for thetype of multicultural patients they encounter.
NON-VERBAL COMMUNICATIONGood communication skills are nowhere more importantthan in the profession of nursing. Ninety per cent of com-munication in nursing practice occurs during direct careor nursing practice related to the treatment of thepatient.1,6 This factor was also mentioned by the researchparticipants and reflects the importance of communica-tion skills in nursing practice. Communication extendsbeyond fluency in languages, it includes non-verbal com-munication. The ability to communicate effectively is nota natural skill, and some individuals are better at commu-nicating than others. This occurs because of a number offactors including personality, cultural influences, previousexperiences, physical or psychological disability and need.Communication skills are virtually part of any tertiarycourse; for example engineers learn about communica-tion skills as part of their undergraduate education, so toodo nurses. The type of communication skills must beappropriate to the context in which they will be used;nurses communication skills will have a different focus tothose learnt by engineers. So too will the type of com-munication skills required by nurses in different countries.For example, in Germany as described by the Germanrespondents, it was important to be stoic and reservedrather than open and friendly.This of course will influencecommunication style. In Australian society open, friendlycommunication is promoted. So it is just as important fornew nurses to learn about culturally appropriate commu-nication skills as it is for non-English-speaking immigrant
nurses to learn communication skills in the Australiancontext.
As a result of observation of these cross-cultural com-munication difficulties and evidence from this research,a communication skills program for migrant nurses and other health care professionals was developed by theauthor at the English Language Institute,Victoria Univer-sity of Technology. This course focused on teaching CLDimmigrant nurses and other health-care professionalsabout communicating in the patientcaregiver relation-ship, communicating about relevant health-care issues, aswell as an understanding and application of medical ter-minology and the Australian health-care system. Evalua-tions of these programs substantiate the importance ofcontextually based communication skills.
CULTURAL ADJUSTMENTWho would know better about cultural adjustment ex-periences than someone who has experienced it? The CLDnurses who participated in this research had all experi-enced cultural adjustment in at least two forms: one,adjustment to a new country and two, adjustment to different nursing practice. These nurses can certainlyempathize with patients who have undergone the migra-tion experience. They have shared situations and feelingsthat others who have not undergone a similar experiencecannot share. This experience, and prior experiences,ultimately can have a dramatic impact on how these in-dividuals report/treat illness, or on their behaviour duringhospitalization and subsequent follow-up treatment. Theclassic examples are the immigrants who are refugeesfrom war-torn or politically stricken countries, whosehealth-care behaviours will certainly be different fromthose of a native Australian.12 Such people need to becared for in a manner that takes into consideration thetremendous emotional and physical turmoil they haveexperienced. In addition, nurses who have undergonesimilar experiences, or who have an understanding of thetypes of feelings and changes these persons may have,should be utilized to provide their nursing care. Under-standing of this key issue should be included in nursingcurricula and professional staff development.
OVERSEAS NURSING PRACTICEAnother key issue described by the participants who com-pleted the questionnaire provided examples of the varietyof nursing practices in other countries.This issue toucheson the field of nursing education overseas, as well as dif-
150 P. Josipovic
ferent health-care systems and nursing practices. Recently,the Nurses Board of Victoria sent delegates overseas togather information about nursing practice in other coun-tries (Mary Lafferty, pers. comm., 1995) in order to assistthe Board make more informed decisions about overseasnursing qualification recognition. This step has at leastacknowledged that more information is required aboutoverseas nursing practice and, hopefully, this informationwill be used not only for qualification recognition, but alsoas an educational resource that can be developed for muchfurther use by individuals and health care organizations.It is important that other nurses have an understanding of the variety of nursing practices around the world. Toooften, nursing professionals, metaphorically speaking,wear blinkers and cannot see any other form of nursingpractice but that in which they have been educated. Nursesshould be more open to and accepting of different ways ofpractising nursing.
Teamwork was another area from the data where rec-ommendations could be made.This concept alludes to ele-ments of collegiality, mateship and, as one respondent putit, the ability to look out for each other. Respondentsalso suggested that teamwork was a priority even throughdifficult times, such as when a nurse was ill or absent.Thisis something that can be stressed in nursing curricula andreinforced in the practice setting. Teamwork involves notonly fellow nurses, but also the remainder of the health-care team. This is an expectation of some CLD nurses,which has beneficial ramifications for the profession, aswell as for the health-care organization in terms of highproductivity, low sick rate, high staff morale and increasedmotivation.Working as a team can be encouraged throughprofessional staff development, awards, and throughchanges in nursing curricula.
NURSING ETHICS AND LAWComments relating to question four of the questionnaire,Can you describe any differences you found in your original homeland or other overseas experiences, andwhat you found in the Australian Health Care System?suggested that Australian nurses are more legally and ethically aware of their role and responsibilities than their CLD counterparts. One respondent from the ques-tionnaire stated, Australian nurses more involved inpatients hygiene and have strong awareness about legalissues which affects nursing practice. This could be dueto the fact that the Australian public are becoming moreaware of their rights and conscious of their own health-
care needs. Legal action against health professionals,including nurses, is not uncommon. Frequently, through-out the answers to the questionnaire, there were com-ments that suggested that in some countries the patientaccepted the care and treatment without question, so thatlegal and ethical issues would be viewed differently. Anexample of such comments: more patient involvement aspatient is more medically aware in Australia than in mycountry. Patients from CLD backgrounds should haveaccess to information about choices and their rights aspatients in languages that they can readily understand, aswell as information about what they can expect from the health care services of the health system they are util-ising. Respect for the patients decision to be informed ornot to be informed should also be adhered to. Again, thisissue has major implications for nursing curricula andpractice.
STATUS OF NURSINGIt was identified in the interview data that for many CLDnurses the status of nursing in their countries was quitelow. This perceived low status by CLD nurses would in-fluence their behaviour in relation to nursing practice, forexample, subservient roles. In Australia, nursing educationhas only recently (in the last 10 years) entered the academ-ic arena. This move has certainly strengthened the statusof nursing as a profession in Australia. The issue of statusalso has implications for how CLD patients view nursingpractice or their expectations of nursing practice. Forinstance, as was indicated in the interview data, manycountries have had nursing education take place in tertiaryorganizations for many years and nurses were on a parwith doctors or a teenie weenie bit below doctors,nursing always a career. This indicated that patientswould regard nursing highly, comparing it to medicine,which had high status in all instances in the data.An under-standing of how respect and the high status of nursing canbe reflected in current nursing practice in Australia tomeet the expectations of certain cultural groups would beanother recommendation.
The variety of nursing practice and standards of nursingpractice was well documented in the interview data:
In Australia too much emphasis on the treatment and not on the
relationship with the patient.
Nurses were allocated tasks, the lower you were on the rung the worse
jobs you got.The good work was done by the nurse in charge.
Culturally sensitive nursing care 151
Much more responsibility on your back in Australia from where I
come from, no signing for drugs, no report writing.
Nursing practice is inextricably linked with the statusof nursing as a profession and the theoretical conceptsunderpinning the discipline. Again, this area reflectedexpectations of CLD patients of nursing practice, asreported by the nurses surveyed. Many CLD patients andnurses would expect to develop a therapeutic relationshipbetween the nurse and the patient, which may includesharing very intimate problems with the nurse: thepatient is everything to us,really get to know the patientwere some of the typical responses. In Australia, due to a variety of factors, the time nurses spend by the bedsideis diminishing. The advances of technology, staff cuts andminimal length of hospital stay have all contributed to thischange. It is important for nurses to know what expecta-tions the patient will have in terms of a therapeutic rela-tionship with the nurse that can ultimately assist in thecare of the patient. Efforts should be made to ensure thatthis is catered for within the unavoidable constraints suchas adequate patient:nurse ratios.
INNOVATIONS IN NURSE EDUCATIONOther teaching methods such as the utilisation of Transcultural Nursing Kits, as developed by Olga Kanit-saki at La Trobe University, Melbourne, and by theQueensland Nurses Board are very useful resources forprofessional staff development, for educational institu-tions or for individual nurses needs. Teaching method-ologies such as the case study approach, where particularcultures (some of the more prevalent or common in Australia) are examined in depth as examples, and guidingprinciples are utilized in order to learn how to give appro-priate care to patients from these cultures.
The research participants made some suggestions ofhow to increase cultural awareness and understandingthrough innovative teaching, for example, by involvingguest speakers/consultants, such as CLD nurses or promi-nent members of ethnic communities.
Governments have commissioned a number of reports(for example, Removing Cultural and Language Barriers toHealth,13 In Fair Health? Equity and the Health System14
and Healthy Participation15) and developed policies such
as Medicare and the National Agenda for Multicultural Australia,16 which acknowledge the needs of Australiasmulticultural population and make recommendations such as the employment of Multicultural Service Coordi-nators or people in similar roles. Individuals who under-take these roles also have the responsibility of assisting notonly patients but also health care professionals to tackleissues associated with delivering culturally appropriatecare.
During the orientation phase of a nurses employment,or even at an interview, nurses should be aware of the cul-tural groups that utilize that particular health care service.In addition, they should be able to identify their ownlearning needs in relation to these issues and be able to beself-directed and motivated in following up these issues inorder to provide a high standard of nursing care to allpatients regardless of sex, age, gender, race or colour.17
If the culturally linked nursing care factors such as touch,respect, gender and family that were explored in this studyas a result of the literature review are not addressed in anydetail in nursing curricula, as is suggested is the currentsituation by DCruz and Tham,11 or in nursing employ-ment situations, then there is a great disservice occurringfor the people whom nurses are supposed to be caring for. Professional staff development seminars or changes tonursing curricula should be instigated in consultation withnursing leaders in this field, such as the newly formedTranscultural Nursing Society which is a specialist interest group of the Royal College of Nursing Australia.Through these leading nursing organizations, changes cantake place in the roles and responsibilities of nurses and,as a result, changes in nursing employer expectations interms of the competency of nurses to care for the largeethnic groups within Australias population will alsoemerge.
CONCLUSIONSLearning about and tolerating different situations can be quite daunting for all who are involved in the new experience. Hofstede writes:
Feelings of uncertainty are acquired and learned.Those feelings and
the ways of coping with them belong to the cultural heritage of soci-
eties and are transferred and reinforced through the basic institu-
tions like the family, school and state. They are reflected in the
collectively held values of members of a particular society. . . . They
lead to collective patterns of behaviour which may seem aberrant
and incomprehensible to members of other societies.10
152 P. Josipovic
5 Nurses Board of Victoria. Guidelines for the use of com-plementary therapies in nursing practice. Nexus 1996; 2: 9.
6 Kleinman A (ed.). Culture, Illness and Healing: Studies in Com-parative Cross Cultural Research. Dordecht: Reidel, 1981.
7 Saunders R (ed.). Cross Cultural Issues for Health Professionalsin Australia. University of Sydney: Multicultural Centre,1990.
8 Helman. C. Culture, Health and Illness:An Introduction forHealth Professionals. Bristol: John Wright and Sons, 1993.
9 Johnson R. The culturally diverse student. Nursing andHealth Care 1990; 10: 402.
10 Hofstede G. Cultures and Organisations: Software of the Mind.London: Graw-Hill, 1991.
11 DCruz J, Tham G. Nursing and Nursing Education in Multi-cultural Australia:A Victorian Study of some Cultural, Curriculum,and Demographic Issues. Melbourne: David Lovell, 1993.
12 Tung T. Indochinese Patients: Cultural Aspects of the Medical andPsychiatric Care of Indochinese Refugees. New York: WalterBros, 1980.
13 National Health Strategy. Removing Cultural and LanguageBarriers to Health. National Health Strategy Issues Paper No.6. Canberra: Australian Government Printing, 1993.
14 McClelland A. In Fair Health ? Equity and the Health System.National Health Strategy Unit Background Paper No. 3.Canberra: Australian Society Publishing Company, 1991.
15 Kearney J, Ednie G, Newton B, Beissbarth E. Healthy Participation: Achieving greater public participation andaccountability in the Australian health care system. NationalHealth Strategy Unit Background Paper No. 12. Canberra:Australian Society Publishing, 1993.
16 Advisory Council on Multicultural Affairs. National Agendafor Multicultural Australia. Canberra: Australian GovernmentPrinting, 1989.
17 International Nurses Congress. Code for Nurses. 1973.
It is clear then that what is different can be seen asthreatening, rather than good or positive, or as a learningexperience or conceptual enlightenment.This premise canhold true for CLD patients and nurses and their experi-ences in the Australian health care system.
Findings from the questionnaire and interview data andthe resultant themes clearly indicate that nurses fromCLD populations have different expectations and per-spectives on nursing practice when compared with Australian nursing practice, because they were originallytaught in, and have experienced nursing practice in,countries other than Australia. Their nursing practice is in tune with meeting the cultural health needs of their clients from the countries where they have practised.This research has not intended to identify CLD nurses as the fountain of all cultural nursing knowledge, only tosuggest that they are a very useful resource that has beenlargely untapped to meet the needs of multiculturalpatients.
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