America continues to be a melting pot of immigrants and cultures. Boyle and Andrews (1989) indicate that more than 106 different cultural groups, excluding native-born American Indians, live in this country. The integration of these various cultures into mainstream Ufe is an extremely complicated endeavor. Some people of different cultures still reside in isolated communities; however, unlike our earliest immigrants, recent arrivals to the United States must adapt to the ways of the mainstream in order to attend school or maintain employment. This adaptation does not mean that these individuals have incorporated all of the mainstream's thoughts into their own beliefs. Instead, they live in two cultures: one with their family and one with the larger community. Having to live closely with two value systems increases both stress levels and the potential for conflict.
Today's health care providers see, on a daily basis, the signs of this stress and conflict in America's culturally diverse population. Nursing has responded to this tension by teaching nursing students, from their first clinical experience, that they must be sensitive to their patients' cultural beliefs. Each patient's individuality is stressed with a major portion of this individuality based on the patient's cultural background. In order to provide individualized care, nurses attend to cultural food preferences, cultural reactions to pain, cultural health practices, and the need for specialized visiting hours to address family members' caretaking styles. Tb facilitate recovery, nurses realize that they must give priority to their patients' cultural beliefs (Boyle & Andrews, 1989).
Yet, what happens when the person who is culturally different is not a patient, but a co-worker, or a manager? In the nonpatient relationship, nurses pay little attention to cultural beliefs and how these diverse beliefs affect the work setting. Suddenly, nurses forget cultural differences and assume that all staff members have the same beliefs. This approach can impede the attainment of work-related goals and professional growth.
In organizing a nursing unit, one must understand the cultural differences of staff members because differing cultural beliefs can result in inappropriate reactions to patients, families, co-workers, managers, and physicians. Without addressing these differences, understanding is difficult; basic problems in communication can result. Nursing management texts identify that communication problems frequently cause inefficiency and decrease the effectiveness of a nursing unit, but these texts rarely bring cultural influences into their discussions on communications.
Every day, nurses see communication and management problems that have a cultural basis in situations such as:
* In a nursing staff meeting, there is a creative nurse who never expresses her views about unit management. Is this nurse from a culture where questioning the supervisor/manager is not acceptable behavior?
* A nurse does not question a physician's order, even though the nurse knows that the order is ambiguous. Is that nurse from a culture where physicians are above reproach and even asking a question for purposes of clarification is not acceptable behavior?
* A compassionate nurse becomes hostile to the family of a patient who is awaiting nursing home placement. Is this nurse from a culture where the oldest child, not a nursing home, assumes hands-on responsibility for the care of the parents, regardless of the personal or financial expense?
The standard response to these and similar scenarios is that culturally different staff members must play by the mies of the mainstream culture. But, how can they if they do not understand the rules of the mainstream - and the mainstream does not understand any other rules, and is not comfortable in discussing the topic? Without open communication, the basis for the problems remains unidentified.
It is important that nurses become sensitive to the cultural differences of their co-workers and the effects that these differences can have on the work setting. Nurse educators play an important role in increasing this cultural awareness. Lectures on the impact of cultural differences in a nursing unit will help to alert students to problems arising from cultural diversity, but this teaching technique is incomplete in covering the topic's depth. Lecture alone cannot bring out individual feelings nor begin to open communication channels. Therefore, in order to heighten students' total awareness of the impact of cultural diversity in the workplace, an interactive learning project was developed for use in a nursing management course. This nursing management course was part of the required curriculum in a BSNcompletion program at an urban health science university. The majority of the students in the program work full-time and attend class on a part-time basis.
This project required that each student interview a nurse (or nursing staff member), not of the American mainstream, about his or her cultural beliefs. An interview schedule was developed that included questions concerning the status of physicians, nurses, and women; reaction/ responses to authority figures; financing health care; family responsibilities in providing health care; artificial life support; the value of work; and the value of time. The student did not need to adhere to the interview schedule but had the freedom to conduct the interview as needed in order to learn more about the staff member and how the staff member's cultural beliefs would have an impact on his or her working in the American health care system.
After the students completed their interviews, groups of three students each had to analyze how staff members with diverse cultural beliefs could meet patient care needs along with unit and professional goals. This analysis was then presented in an oral format to the class, and in a written format read by the instructor.
At the start of this project, the students felt that they understood cultural diversity as it was covered in their preparatory nursing programs in relation to patient care needs. By the completion of the project, many of the students commented that they had never looked at cultural diversity in the workplace before and were astonished by what they did not know. They felt that the project helped them to understand the broader scope of cultural diversity and how it affects the work setting. Those students who worked on units with a culturally diverse staff indicated that some of the initiatives attempted by the unit had failed because the initiatives were not presented in such a manner that culturally diverse staff members could understand their importance and thus provide support. Through discussion, the students were able to stress that a person's culture did not negate his or her individuality. Instead, both individuality and culture needed to be addressed whether the other person was a patient or a coworker.
The students were surprised by the reactions of the nursing staff who were interviewed. The interviewees were pleased to grant the interviews, feeling that the students cared enough about them as persons to ask about their background. In several cases the interviews resulted in the culturally diverse staff members gaining a better understanding of their work setting and the rationale for certain policies and actions. In situations where the student and the interviewee worked on the same unit, the sharing of cultural reactions to different incidents became an ongoing part of the work environment.
In evaluating the information obtained from the interviews, the students, who had all been practicing for several years, were frank in their statements on the minimal amount of attention they gave to how a culturally diverse staff member could misinterpret policy changes, communication expectations, and nursepatient interactions. Realistically, the students admitted that the work setting could not change to meet the cultural wishes of each staff member. However, the project helped the students to understand that their communication techniques had to allow for assessment of how one's own cultural expectations interface with the cultural expectations of others. The students realized that an effort must be made to have culturally diverse staff work through the conflicts that arise from being part of two cultures.
The goal of nursing education is to prepare a competent health care provider. A part of this competence is the nurse's ability to work with others. As nursing staff become more culturally diverse, educators must take steps to assure that today's student is prepared to function with that diversity. Cultural awareness and sensitivity to the differing beliefs of co-workers will help to alleviate some of the stress that surrounds today's nurses.
- Beyle, J.S., & Andrews, M.M. (1989). Transcultural concepts in nursing care. Glenview, IL: Scott, Foresman & Co.