Benner (1984) has described the process of moving from novice to expert as requiring that the individual experience and process critical incidents to help establish a basis for future decisionmaking. Most nursing studente are introduced to the concept of cultural assessment very early in their programs, and the cultural dimension is commonly recognized as a central aspect of each individual. However, without the opportunity to care for culturally diverse cliente, it is as though students were instructed in physical assessment but never given the opportunity to listen to heart or lung sounds. It is not surprising that even experienced community health nurses describe themselves as not confident in working with culturally diverse clients (Bernal & FVoman, 1987). This article describee our experiences working with American Indian clients in a community health setting through the Indian Health Service and a tribal home health agency (IHS/THH) and the various frustrations and successes of this clinical experience. Insights gained during the process and ideas for implementing this type of experience are shared.
Leininger (1991) states that students find that transcultural nursing offers them the opportunity to appreciate individual clients and their culture and to develop ways of working cooperatively with clients. Students learn from clients even when offering them information and assistance. In the community health setting, the culture of the community determines what nursing activities will be allowed - nursing can only be effective if it takes place in a culturally acceptable context. As expressed by a student:
Textbooks don't talk about the time involved in establishing that trusting therapeutic relationship before you can ask all these helpful questions. No matter how you look at it, it's a time-consuming process if your client is suspicious of you. A captive client in a hospital bed is another matter!
The concept of cultural imposition describes the ways that health care providers impose their own cultural beliefs on clients, in the opinion that the professional caregiver's values are more correct, This ethnocentric view prevents nurses UOm interacting with clients or communities in effective ways (Leininger, 1991X Students in this community health practicum invariably describe frustration with "Indian time," which is described by American Indian staff as situation-oriented rather than clockoriented. It seems to students that the priorities of the staff members, including nursing stafi) are not consistent with what students feel is important. Students are anxious to visit many ch'ente, gain physical assessment and technical skills, gain as much information as possible, and accomplish clinical assignments in a timely lashion. Initially, it seems that there is too much time spent getting acquainted with the reservation and IHS/THH policies. As the semester progresses, the students' logs indicate a developing appreciation for the organization of the agency, the approaches to clients, and the priorities of the American Indian staff
Recognizing that I planned to earn an A in this class, frustration grew as I became concerned that I might not be able to satisfy class objectives in this clinical setting. That frustration peaked at mid-semester when studente in other clinical settings were following three clients and I had only just begun a therapeutic relationship with my first! My instructor had forewarned me of the likelihood of a slow start in this clinical setting but I promptly disregarded her words. Fd grown up on one reservation after another, my dad had been a Bureau of Indian Affairs employee, I knew about Indian people. But these people didn't know me. I felt foolish to have been so egocentric, but I was no longer frustrated. A good lesson was learned. I became more comfortable functioning within the present time orientation, and living the experience became wonderful.
As students spend more time in the community, they gradually become known and accepted by health care providers and clients. It is a very affirming experience to have doors opened to them that once were closed.
The client . . . got well enough to return to work. I spent two miserable weeks trying to catch up with him to offer interventions and monitor his progress. After sitting for 45 minutes on two different occasions in a restaurant he was known to frequent, the waitress said, "We haven't seen him either. Maybe he doesn't want to see you . . . maybe that's why he's not coming in here anymore." I left chagrined and wondering if she might be right!
Feeling I had nothing to lose at this point, I wrote a note, boldly stating that I would be at his house at 7:00 a.m. the next week, that I hoped this would be convenient for him, and that I looked forward to seeing him. God was smiling on me that day. The wind was blowing so fiercely that I feared my note tucked in the screen door would be blown away. Looking around I selected a brick from one of the refuse piles in his yard, sat it on the porch, and placed my note beneath it.
I was shocked and amazed when a shining, smiling face opened the door to me the following week and warmly invited me in. He did not have work until 8:00 a.m. and if we didn't take too long this would be a perfect time for him. He thanked me for not leaving my note in his screen door! One of his biggest problems with white people had always been that he had not been able to get them to realize that a note in his screen door gave notice to robbers that no one was home. We continued to meet every week and many notes were left under the brick.
When a note was expected, a brick awaited me on the porch. I will never forget this man and all that he taught me.
Sharing in Cultural Secrets
An especially satisfying experience in transcultural nursing is to be included in the life of a client or the community and admitted to cultural practices not casually shared with strangers. These experiences must be earned through the process of developing relationships and establishing trust between the student and the client or community. Leininger (1991) states that these cultural secrets will frequently give new direction to nursing care. Recently, students were honored by being asked to go on an annual "root-digging" expedition with the home health staffi
It was a woman's day, a day for women aged 11 to 55, a shared spiritual experience, different for each woman, an opportunity to hear stories and to learn about a time that is no more, and to ask questions that you never thought you could ask, a day to become closer to these women.
Root-digging was a wonderful experience. We dug wild potatoes in the woods with cuppins. We also dug bitterroot on a high open plain. There was lots of driving on bad roads and on the restricted part of the reservation where only tribal members and invited guests are able to go. We saw wild carrots and onions and dug a root that could be mashed and baked like hard tack. It is hard to describe how beautiful and peaceful the day was.
Benefits to Other Students
The students' peers, who have more conventional home health or public health nursing clinical experiences, also benefit from the transcultural experience of the other students via the sharing of experiences and insights during clinical conferences. For example, students are encouraged to share their early frustration with not seeming to make progress in obtaining clients for independent visits, with not accomplishing course requirements in a timely manner, and with clients' "noncompliance* with health care providers' suggestions. This provides an opportunity for discussion about transcultural nursing and why imposing one's expectations on the community and the clients may n°t lead to success. The concept of trust and how trust may be obtained by health care providers who are not part of the dominant culture on the reservation can be introduced. It also provides a chance to offer reassurance that during the course of the semester all required clinical experiences will be accomplished. It would be fair to say that the students with the more mainstream experiences may be congratulating themselves on not having chosen the IHS/THH practicum at this point in the semester.
As the semester progresses, clinical conferences give the students the opportunity to share successes and insights with their peers and to offer suggestions in working with clients from different cultures. The entire clinical group is exposed to the practice of transcultural nursing and learns to appreciate the necessity of practicing nursing within the culture of the client and community.
Developing and Planning Transcultural Experiences
In organizing the practicum and guiding students through the course, the most useful tools to the instructor are good communication skills and a commitment to developing and maintaining a good relationship with the staff at the agency. It is essential that staff members and clients be the leaders in educating instructors and students about the culture, the agency, and the client needs. Experienced American Indian and Anglo staff nurses, who are experts in the dynamics of the community, are utilized as student preceptors. With the instructor, as with the students, the development of trust and satisfying relationships is not an overnight occurrence. Relationships of mutual respect and trust develop slowly over the course of several semesters. It may be helpful for instructors to share their own frustrations and satisfactions with students as students progress through the semester.
At the end of the semester, during clinical conference discussion of the IHSTHH clinical experience, students typically have some insights to share about how certain critical experiences have changed their views of themselves, their clients, and the community. Most students have not only gained information about the local tribal culture but also feel truly changed and enabled by the experience to function more competently in this multicultural community.
As a nursing student, each new experience is filled with opportunities and fears unique to the situation. Indian Health as a clinical setting for community health practicum was no exception. This setting was different from any that had been previously experienced, in that the sense of hurry and anxiety present in most hospital clinical sites seemed to be replaced by a much slower and calmer attitude.
At first I felt myself to be frustrated and eager to be busy accomplishing something useful. My experiences to date had not included transcultural nursing, even though I have lived on this reservation for many years. It is interesting to realize how little I know of this culture and its customs and heritage. It became apparent after a few weeks of anxious waiting that a trust-building phase was being passed through.
The staff with whom we worked were primarily American Indian and their feeling toward their clients was quietly protective. Early on, I interpreted this to be an indirect statement about myself; but later realized that it was difficult to take white women, students at that, into some of the more traditional homes. This realization both embarrassed and saddened me, as I meant no harm, Education is often gained in ways that are not detailed in a syllabus; through this experience I have learned about being open and to receive what is being offered.
Benner(1984) describes knowledge based on theory as "knowing that," and knowledge derived from personal experience as "knowing how." To gain the "know how" to approach clients from cultural backgrounds other than their own, students can be provided with a guided clinical experience in transcultural nursing and not simply given theory about cultural assessment without the opportunity to practice transcultural nursing.
- Benner, P. (1984). From nouice to expert: Excellence and power in clinical nursing practice. Metilo Park, CA: Addison-Wesley.
- Bernal, H., & Froman, R. (1987). The confidence of community health nurses in caring for ethnically diverse populations. Image: The Journal of Nursing Scholarship, 19, 201203.
- Leininger, M. (1991). Transcultural nursing: The study and practice field. Imprint, 38, 55-66.