The facts I have learned about blacks and their family dynamics has helped me to eliminate some of the stereotypes I have had due to faulty or nonexistent information." This statement, made by a graduate student enrolled in a course entitled, "The Nursing Process: Ethnicity and Aging," reflected an "aha" experience. The graduate course was an integral part of the gerontological nursing sequence in the Master's Program in Nursing at the University of Kansas College of Health Sciences, School of Nursing.
The purpose of this article is to describe the objectives, content, methodology, course requirements (theoretical and clinical), and the evaluative process of the course, "Ethnicity and Aging."
This course was designed as an outgrowth of the philosophical belief of the instructors that knowledge of the individual's culture, health beliefs, and practices is essential to individualizing approaches to nursing care. Need for this course became apparent with recognition of the multi-ethnic groupings among the elderly population in a large mid western metropolitan area. Populations of varying ethnic groups in public high-rise housing and in the community, pointed out the need for education of professional nurses with respect to the culture, health beliefs, and practices of these groups and the clinical application of this knowledge. Knowledge of various cultures is necessary if, in fact, support of the glibly repeated phrase "individualizing care" is to be demonstrated. While commonalities arise out of the basic humanness of individuals, there are also differences that should be respected, based upon thecultural beliefs and practices of those having different ethnic origins.
Philosophically, the course was based on the premise that culture and nursing are intertwined. Nursing is people oriented. Nursing care is given to ethnic individuals by nurses who also have a particular ethnic origin, and nursing, as a profession, has tended to be monolithic in its approach based upon health beliefs arising out of the cultural background of its members. Since the majority of nurses are Caucasian, little attention has been directed toward curricular development that would support cultural differences and values of those from other cultures. Failure to recognize the particular health beliefs and practices of those seeking care from nurses of another culture may negatively affect the outcomes. Therefore, to discharge its mandate to society, nursing curriculum should include content and clinical experience, in keeping with the ethnic composition of the society it serves.
Two definitions upon which this course was established were: (1) ethnicity, and (2) culture. In this case, ethnicity was viewed as the particular life style, beliefs, and practices of a relatively large number of people grouped together to achieve their common goals. Culture, on the other hand, was depicted more specifically through the preferences of a particular group in such areas as language, diet, values and choices, including beliefs about health and health/illness care practices. Of particular concern were the unique needs of aged individuals from various cultural backgrounds and respect for their basic humanness.
The course description was as follows:
This course will provide opportunity (or the student to implement the nursing process with aging clients/patients having varying ethnic origins and cultural patterns. Exploration of beliefs about health practices, and cultural environment of selected ethnic groups will be made in gathering data essential to the nursing process. Knowledge of ethnicity and aging and sensitivity to the individual differences of aging clients patients in carrying out the nursing process are expected student outcomes. Community resources and services will be assessed in relation to meeting needs of aging individuals of various ethnic origins.
Upon completion of this course the students are expected to:
1. Identify major differences between selected ethnic groups with respect to their health beliefs and practices.
2. Describe the cultural environment of selected settings where client patient nurse interaction occurs.
3. Implement the nursing process in keeping with the needs of aging clients/patients of varying ethnic origins and cultural patterns.
4. Incorporate the biopsychosocial, spiritual parameters into a holistic approach to care.
5. Assess community resources using those appropriate to the needs of aging individuals of various ethnic: origins and cultural patterns.
6. Evaluate the outcomes of nursing intervention based upon the written objectives of the care plan and the ?ΝΛ Standards of Gerontological Nursing.1
The didactic portion of the course was presented in a three-hour seminar approach based upon the andragogical model of learning. Principles of andragogy were used to promote student learning in which increasing self-directed activity was the major focus. This methodology contributes to the development of qualities needed by the professional nurse who accepts responsibility and accountability to the clients/ patient population with whom she interacts.2 This approach fosters the development of social roles and relationships contributing to the internalization of qualities and externalization of characteristics essential to the role of the clinical nurse specialist.
The nursing process afforded a framework for organizing the theoretical and clinical approach to the ethnic aging client patient and his family, or significant other. Components of the nursing process emphasized were assessing, diagnosing (nursing diagnosis), planning, implementing, and evaluating. Assessment, the first stepof the nursing process, included course content, didactic and clinical, on the procedure for health assessment, eg, interviewing, history-taking, and health assessment skills for data collection in the physiological, psychosocial, and spiritual domains. For example, one student encountered a male client in a high-rise housing unit for the black elderly who greeted her at the door of his apartment with a sharp instrument in his hand. She discovered, during the interviewing process, that, for this man, this instrument was perceived as harmless. He indicated the need for control of his environment based on his past experiences. This data was vital to the nursing diagnosis and the evolving plan of care.
A second aspect of the nursing process, diagnosing, follows collection of data. In the case cited above, need for establishing a trusting relationship and communication with someone who could understand and accept his behavior was paramount. This diagnostic component was followed by evident need for further follow-up on mental status and need for care.
Following completion of assessing and diagnosing components, planning, implementing, and evaluating outcomes of the written plan of care and proposed nursing action were emphasized in the course. For example, in planning and carrying out the rest of the nursing process, in the case described above, included working with this older gentleman to help him learn to interact with others in the high-rise setting who were interested in him as a person and who were trustworthy. At the end of this semester in evaluating the outcomes of this specific nursing action, the student recounted that this man was comfortable in leaving his apartment and traveling to nearby nutritional and recreational sites for socialization purposes. This gave evidence that implementation of a systematic approach, eg, the nursing process with identifiable steps could be made and outcomes clearly delineated. This approach afforded a means whereby appropriate community resources could be used and the ANA Standards of Gerontological Nursing Practice promoted and maintained.
Teaching methodology of the course included lecture and discussion, student presentations on selected topics such as: "The Meaning of Culture"; "American Cultural Values and Nursing"; "Cultural Variations and Life Style"; "A Forum, The Oriental Cultural Group"; "The American Indian: Health Beliefs and Practices"; "The Afro-American: Health Beliefs and Practices"; "The Mexican-American: Health Beliefs and Practices"; "Other American Cultural Groups: German, Italian, Czech, Swedes"; and "Health Institutions as Social and Cultural Systems."
Clinical experience with their clients and family members was obtained in various settings. These settings included homes, senior citizen's centers and nutrition sites, institutions for specific ethnic groups, and public agencies such as the Visiting Nurses' Association and Health Departments. This clinical experience of six hours per week provided student involvement in the community in health care delivery patterns on a broad spectrum.
More specifically, close clinical supervision of students developing health care assessment skills was achieved in a nurse-conducted clinic near the university. Clientele seen at the clinic were from the major ethnic groups in the area. Students were expected to perform two to three health care assessments per week to gain skill and proficiency. Recording of findings included strengths of these aging individuals and specific information obtained during the assessment process. The problem-oriented method was used for this charting. These charts were retained in a central file in the gerontological nursing office, following review by the clinical instructor.
In summary, the course, "The Nursing Process: Ethnicity and Aging," required presentations by the students on selected topics; two annotated bibliography cards per week on references related to the seminar topic of the week, which also included a critique of the material and implications for nursing, identified by the student. These cards, submitted for grading each week, were returned with written comments by the instructors. The health assessment paper was presented during a class session. This type of presentation is considered an important part of developing communication skills of graduate students, written and verbal. Required agency reports included a listing of agencies being used by the clients/families being followed in the clinical practice session and an evaluation of the stated objectives and services offered by the agencies.
Evaluation of the course requirements was based upon the following criteria: seminar presentation- 30%; bibliography cards-15%; health assessment paper-30%; and agency reports-25%.
Additional informal evaluative feedback included comments from students. One student indicated she had taken several liberal arts courses dealing with culture and thought she understood what culture was until she started taking this nursing course. Faced with carrying out a health assessment on a Hispanic male client, who could not speak English, pointed out ethnic variations and some adaptations the nurse must make to be effective. Speaking through an interpreter slowed the assessment process and brought sharply into focus differences based on language. In another situation, interaction with an elderly lady from the Sioux Indian tribe revealed the fact that this individual lived off the reservation by choice. The student expressed surprise upon learning that an Indian would choose to live in an urban setting, relatively isolated from tribal members. The Indian lady was socially well adjusted and shared that she was writing a book entitled Life on the Reservation. This activity seemed to indicate a sense of belongingness, in spite of her choice of living arrangement. In still another instance, a student interacted with a Spanish speaking client in need of medical care, whose citizenship status was in question. This situation raised the issue of legality with respect to immigration regulations.
A black student described her experience with a Jewish resident in a Jewish Home for the Elderly. The gentleman took it upon himself to teach the student about the beliefs and practices of orthodox Jews. He took her to the synagogue and showed her the torah, the sacred book of the Jewish religion. He also explained the intent to be with a person during the dying process and the desire to carry out the particular religious rituals at the time of death.
Reactions of the students verbalized spontaneously, provided additional evaluative data. This data was important with respect to student development and to evaluation of the course.
This course has been taught several times. Evaluation of this course by the students has given strong indication of its value from the theoretical and clinical frames of reference. Students expressed the thinking that this course should be required for all students in the Master's Program. In addition, they indicated that professional nurses working in an institutional or community setting where older people of varying ethnic origins would be found should be educated in the components of ethnicity as it relates to aging individuals.
- 1. American Nurses' Association: Standards of Gerontological Nursing Practice. Kansas City. Missouri, ANA. 1976.
- 2. Knowles MS: Issues in adult learning psychology. Adult Leadership 22(9): 300-303. 315-316, March 1971.