CASE/ STORY

Challenges of a New Mandate

By 7:00 am, Jacqueline Strong is already in her office, preparing for the day to come. As a Clinical Nurse Manager on a busy pediatric unit at Kendrick Hospital, she is in charge of patient care and training. She also chairs a hospital committee for Cultural Competence. Last month, the Board of Trustees unveiled its 10-year Strategic Plan. Objective #3 mandates that the entire hospital, from an individual to an organizational level, must demonstrate the ability to provide culturally competent care. Helping achieve this goal has become another one of Jacquelines responsibilities. Prior to the Boards development of the Strategic Plan, Kendrick Hospital conducted an organizational self-assessment of cultural competence. Staff in different departments was asked to complete anonymous selfassessments in cultural competence. Jacqueline was quite concerned when she looked at the nursing responses. She knows that the department has a long way to go. For many years, Kendrick Hospital has served a blue collar, Irish Catholic neighborhood on the edge of Chicago. Many of the nurses are from this neighborhood (many of them grew up here) and hospital staff and patients have enjoyed a feeling of close camaraderie. They have also taken particular pride in Dr. Jamieson, a nationally known oncologist who was recruited to develop a satellite oncology program to be affiliated with the larger Metro Healthcare Center. Recently, a number of Romani patients have been coming to Kendrick. They frequently ask for Dr. Jamieson, even if the problem for which they are seeking help is not cancer. While perceived by some as loud and demanding, the Romani patients seem to have an admirable ability to negotiate the system, obtaining the information they need and getting appointments with the physicians they wish to see.
Romani, the adjective; Romani, plural noun; or Roma, singular noun, are the preferred terms when referring to people commonly and incorrectly known as Gypsies. Gadje (or gazho) is the plural term referring to non-Roma. An individual Romani household is a familia consisting usually of three generations of six to fifteen relatives. Families are male dominated, with a group of male elders within the familia being the major decision makers. Romani women are often not included in the decision making process and generally have a much more subordinate role. The Roma originated in India and migrated to Europe by the 15th century. A large Romani migration to the United States occurred, from Russia via Argentina in the 19th and 20th centuries. The Romani language is derived primarily from Sanskrit. Education and technology have not traditionally been considered important. Many older Roma are not literate. Roma are generally a nomadic people. They have traditionally adopted the dominant religion of the area in which they live. They also maintain beliefs in the supernatural, omens and curses and may carry charms, amulets and talismans in their pockets for safety, good luck and to prevent illness. Romani female healers, called drabarni or drabenhgi, prescribe traditional healing rituals and cures. The Romani people tend to use the Gadje health care system only in crisis situations when there is an acute and/or unresolved condition for which folk medicine has failed. Most Roma make a concerted effort to remain socially isolated and invisible. In the United States Roma often present themselves as members of one of the other minority groups in the U.S., due to concerns about the impurity of outside cultures and to the long history of prejudice and misconceptions about their culture. The Roma have a strict taboo code that classifies all outsiders as soiled or unclean. "Wuzho" (pure) and "marim" (pollution or impurity) are important Romani concepts. To maintain purity, Roma are required to follow strict sexual mores. They must wash their hands after touching the lower body before touching the upper body. Separate soap and towels are used on the upper and lower parts of the body and they must not be allowed to mix. Dishes may not be washed in a sink used to wash clothing. Roma believe that polluting actions will result in illness. To return to a state of purity, cure, and good health one must conform to or correct the marim social behavior.

Jacqueline's dilemma
Jacqueline is concerned, however, because the nurses have little to no experience with members of other cultures. Just yesterday, for example, Christy Fitzgerald, a young, enthusiastic, usually cheery nurse came into her office, her voice filled with frustration. She protested that she could not get her work done with that Gypsy girl. Christy said that least 10 of the girls rel atives were in her room at all times, while many others camped out in the hall and waiting room. When Christy entered the room, one of the older men demanded to know why they hadnt seen Dr. Jamieson. When Christy attempted to give the child a sponge bath, several of the women insisted in staying and watching her. As she proceeded, they clearly became angry. Christy couldnt understand what they were saying, but their loud and agitated voices made it clear they wanted her to stop. Later, she tried to butter some of the girls toast, and again she was stopped. Christy thinks she saw one of the girls relatives pocketing some of her medications. She told Jacqueline that she has heard that Romani patients have a reputation for stealing, though she cant imagine why theyd be stealing antibiotics. She thinks just being at the hospital is stealing, in a way, because they clearly have no insurance. Christy thinks the Gypsies lie, too. After all, one of the family members told another nurse that they were Hispan ic and thats clearly not true. And its been hard to get anything done. When the doctor told the girls mother that, with her permission, hed like to use a new medication on her daughter, the mother just wouldnt make up her mind. Christy also thinks the family is at fault because they waited so long before bringing the girl into the hospital. The girl wouldnt have gotten this sick if theyd brought her in right away. As Christy talked, it became clear to Jacqueline that Christy has been approaching this Romani patient and her family entirely from her own perspective, without attempting to understand the familys views and beliefs. Jacqueline knows that she will need to have a long talk with Christy. As chair of the Cultural Competence Committee she will have to provide training for all of the nurses. While the Romani patients present the most immediate need, Jacqueline wants the nurses to learn more generally about how to work with people from diverse cultures. In addition, she is coming to realize that the hospital is not a welcoming place for Romani patients. She recognizes that changes will need to be made at the institutional level, to allow Romani patients to feel more comfortable there.

Interventions at all levels

Jacqueline decides to approach the problem at two levels. First, she holds a series of in-services for the nurses, using Christys experiences with her Romani patient as a starting place for the first one. Jacqueline knows that developing a culturally competent staff will take more than these seminars, and that knowledge does not immediately translate into attitude and behavior change. But she feels this will be a start. She plans also to consider the possibility of asking the Romani elders whether they would be willing to act as faculty, talking with the nurses about their culture and beliefs. She would ideally like this to happen in their homes, but knows that she will have to approach this idea gently, as members of the gadje community are generally seen as presenting an impure and potentially dangerous influence on the Romani community. Simultaneously, Jacqueline and other members of the Cultural Competence Committee write a proposal that she presents to the hospitals executive committee. They would like to develop a special program for Romani patients. This program would involve providing rooming-in accommodations for the larger family groups, special sanitary precautions (disposable plateware and eating utensils; two washcloths and bars of soap; careful attention to Romani concerns); and training to physicians and nurses regarding the importance of communicating with elders and refraining from touching surfaces in the rooms of Roma; sensitivity to the fact that Romani elders may not read and accommodations for this; flexible billing programs to allow Romani patients to pay their bills over time; and appropriate mores for communicating with members of the opposite sex.

What challenges do medical facilities face when trying to become more culturally competent?

Cultural competence is a set of values, behaviors, attitudes, and practices within a system, organization, program, or among individuals which enables the system, organization, program, or individual to work effectively across cultures. One of the challenges medical facilities will face in trying to become more culturally competent is the resistance among some of the staff because there will be some jealousy if hospitals/ medical facilities give to patients. Some staff feels that immigrants should learn how to accommodate to the traditional practices of the hospitals and not the other way around. Another challenge that medical facilities will face is that the process of becoming culturally competent is expensive. Some medical facilities do not have enough budget for this. Lastly, the attitude of health care providers or the health care providers per se is a challenge for medical facilities because in order for the latter to be culturally competent, health care providers working within these medical facilities should also be culturally competent. Health care providers should be flexible and willing to adopt changes and be culturally sensitive in order for the medical facilities to fulfill its vision of becoming more culturally competent.

What kinds of assumptions do providers sometimes make about people from other cultures?

Health care providers sometimes make prejudices about people from other cultures. Prejudice is a belief based on preconceived notions about certain groups of people. It is both an attitude and a cognitive process, the identifiable and measurable outcome of which is the practice of discrimination. In health care, prejudice is differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention. Health care providers sometimes prejudge people (patient) on the basis of race and immigrant status, socioeconomic status, personal appearance and unique trait that some people harbor. Health care providers also sometimes stereotype people from other cultures. They classify or categorize people, and believe that all those belonging to a certain group are alike. Stereotyping in health care may affect patient care because of generalizations made to a certain group based on individual belonging to that certain group. It is inappropriate to stereotype because individuals will always maintain some uniqueness within a group.

What factors may cause providers to relate to patients in a biased manner?

One factor that may cause health care providers to relate patients in a biased manner is the cultural difference between the health care providers and patients. Because of these cultural differences, health care providers tend to treat patients differently- give greater attention to patient with similar race and lesser importance to other race. Another factor that may cause health care providers to relate patients in a biased manner is the attitude of the health care providers. Some health care providers are ethnocentric; they believe that their culture is the best and only acceptable. If health care providers are ethnocentric, they will surely treat patients in a biased manner because they wont able to see the value in other cultures. Therefore, as health care providers, seeing beyond ones own particular ethnic/ cultural group is important for effective communication and understanding of the patients culture.

Saint Marys University

Bayombong, Nueva Vizcaya

Graduate School

In Partial Fulfillment of the Requirements in Master of Science in Nursing- Transcultural Nursing

ASSIGNMENT NO. 2: CASE/ STORY

ABOUT JACQUELINE STRONG

Submitted to: Mrs. Fe Yolanda G. del Rosario, PhD Instructor

Submitted by: Mark Anthony T. Tabago, RN